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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803241
Report Date: 05/26/2022
Date Signed: 05/26/2022 03:14:07 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2022 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20220301155712
FACILITY NAME:BROOKDALE CHANATEFACILITY NUMBER:
496803241
ADMINISTRATOR:CORTES, MARIAFACILITY TYPE:
740
ADDRESS:3250 CHANATE RDTELEPHONE:
(707) 575-7503
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:140CENSUS: 80DATE:
05/26/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Maria CortesTIME COMPLETED:
03:23 PM
ALLEGATION(S):
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Resident's care needs are not being met
Facility is not clean
Staff are not safeguarding resident's property
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis arrived unannounced to deliver findings regarding the above complaint allegations and met with Administrator, Maria Cortes.

Resident's care needs are not being met – Complaint alleges that a resident in care is not having their needs me because they were observed unbathed, unclothed and had lost weight in the last year. During visit on 3/11/2022, LPA observed resident, R1 clothed and appeared clean but their room did smell strongly of urine. During visit, a caregiver came in with R1’s lunch. R1 started eating their food independently. LPA later questioned why the room smelled so significantly of urine and was informed that resident routinely goes to the bathroom in their adult brief prior to lunch but is usually not provided incontinence care until after they have eaten. Documents showed that between March 2021 and March 2022, R1 lost 28 lbs. Facility does not have record that the resident’s doctor was notified.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20220301155712
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BROOKDALE CHANATE
FACILITY NUMBER: 496803241
VISIT DATE: 05/26/2022
NARRATIVE
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Continued from LIC9099

Facility is not clean – Complaint alleges that a resident’s room smelled of urine and the carpet was not clean. During LPA’s 3/11/2022 visit, LPA smelled urine in a resident’s room and observed that their bed did not have a mattress cover and the mattress had urine stains. LPA observed carpet stains throughout the facility. Per interviews, there is one maintenance person and it is their responsibility to spot clean the carpet, but it can be difficult to keep up considering they are the only maintenance person. Additionally, some stains come back and need to be cleaned multiple times.

Staff are not safeguarding resident's property – Complaint alleges that a resident came into another resident’s room and started going through their belongings. LPA confirmed through interview that there is a resident who has a behavior of going into other resident’s rooms. Per interview, staff have observed resident with items belonging to other residents and staff try to redirect.

The allegation that Resident's care needs are not being met, Facility is not clean and Staff are not safeguarding resident's property is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2022 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20220301155712

FACILITY NAME:BROOKDALE CHANATEFACILITY NUMBER:
496803241
ADMINISTRATOR:CORTES, MARIAFACILITY TYPE:
740
ADDRESS:3250 CHANATE RDTELEPHONE:
(707) 575-7503
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:140CENSUS: 80DATE:
05/26/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Maria CortesTIME COMPLETED:
03:23 PM
ALLEGATION(S):
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Insufficient staffing
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis arrived unannounced to deliver findings regarding the above complaint allegations and met with Administrator, Maria Cortes.
Insufficient staffing – Complaint alleges that staff is insufficient as visitors have had to wait several minutes for the doorbell in Memory Care to be answered. During visit on 3/11/2022, LPA rang the doorbell on two separate instances approximately an hour apart and observed that staff did not answer the door. During the first instance, the Administrator explained that it was lunchtime and staff would be assisting residents. The next instance, LPA was let into Memory Care by the Maintenance person. Upon entry, the maintenance person went to look for staff and found the Memory Care Director in their office who then came out and explained to LPA that one staff was momentarily downstairs, and another was assisting a resident. The Memory Care Director showed LPA the pager that caregivers keep on them that showed that the doorbell was rung. While there have been instances of delay in answering the door to Memory Care, eventually access was gained.

A finding that the complaint allegation Insufficient staffing was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred.
No deficiencies cited during this inspection.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20220301155712
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROOKDALE CHANATE
FACILITY NUMBER: 496803241
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/27/2022
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement has not
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Licensee agrees to submit planned date of a staff in-service regarding regulation 87625 by POC due date, 5/27/2022.

In-service to be completed no later than 6/10/2022.
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been met as evidenced by interview and observation showing that a resident was left in a soiled brief until after eating and resident's room smelled of urine. This is an immediate risk to the health and safety nof residents in care.
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Type A
05/27/2022
Section Cited
CCR
87466
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87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional & social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains... are observed, the licensee shall ensure that such
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Licensee agrees to submit planned date of a staff in-service regarding regulation 87466 by POC due date, 5/27/2022.

In-service to be completed no later than 6/10/2022.
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changes are documented & brought to the attention of the resident's physician & the resident's responsible person, if any. Requirement hasn't been met as evidenced by facility not notifying doctor of weight loss. This is an immediate risk to the health and safety nof residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20220301155712
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROOKDALE CHANATE
FACILITY NUMBER: 496803241
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2022
Section Cited
CCR
87468.2(a)(1)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy
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Adminsitrator agrees to submit a written plan indicating what they will do to ensure that residents do not go into other resident's rooms uninvited and/or go through other resident's personal property of resident by POC due date, 6/3/2022.
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in accommodations... This requirement has not been met as evidenced by interviews confirming that a resident in memory care goes into other resident's rooms and goes through their personal items. This is a potential risk to the personal rights of residents in care.
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CCR
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5