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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803241
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:05:26 PM

Document Has Been Signed on 08/13/2024 03:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BROOKDALE CHANATEFACILITY NUMBER:
496803241
ADMINISTRATOR/
DIRECTOR:		LEDESMA, KATELYNFACILITY TYPE:
740
ADDRESS:3250 CHANATE RDTELEPHONE:
(707) 575-7503
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 140CENSUS: DATE:
08/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:08 PM
MET WITH:Administrator, Kelly OrdingTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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At approximately 1:00pm LPA Christi Coppo and arrived unannounced to conduct a case management regarding Incident Report received on 8/9/2024.

On 8/9/2024 facility submitted to CCL Incident Report indicating resident (R1) had eloped. R1 has a diagnosis of dementia and resides in Memory Care. R1 had been recently moved from AL to Memory Care and was experiencing some confusion. On 8/8/2024 resident had been experiencing some restlessness and stopped to rest in a chair outside another resident's room. R1 had fallen asleep in the chair; rather than wake R1, staff let them rest and checked on them as staff performed their shift duties.

At approximately 3:15am, NOC caregiver (S1) noticed that the resident was no longer in the chair. S1 went to check R1's bedroom to make sure they weren't in their room. S1 then alerted Resident Care Coordinator (RCC) (S2) that R1 was unaccounted for. RCC then notified Health and Wellness Director (HWD). While performing checks and searching, police notified the facility that R1 had been located and that an officer was with R1 at a nearby gas station. NOC Med Tech (S3) retrieved R1 from police and escorted them back to the facility. At approximately 3:30am, R1 returned to the facility. HWD performed a thorough head to toe examination of R1 and found resident to be sleepy, but without injury. R1's care plan was updated and increased safety checks were performed every 30 minutes. All required parties were notified.

Upon R1's return, facility immediately conducted investigation of elopement. Investigation found that the north egress door had not latched completely after staff had exited, so the alarm was not engaged. This is the reason for the alarm not sounding when R1 opened it. Maintenance director and Admin conducted staff training and performed an elopement drill which included a demonstration of facility egress doors and alarms. Procedures for locating and searching for residents were also part of the drill. Training log and drill attendance form provided to LPA at time of case management.

Additionally, facility implemented census check and egress door check as part of shift change procedures; checks are completed every shift change.

Continued on 809C...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/13/2024 03:05 PM - It Cannot Be Edited


Created By: Christi Coppo On 08/13/2024 at 01:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROOKDALE CHANATE
FACILITY NUMBER: 496803241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2024
Section Cited

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87705 Care of Persons with Dementia
(c)(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
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This requirement was not met as evidenced by: incident of resident elopment, which poses a potential health, safety or personal rights risk to 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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BROOKDALE CHANATE
FACILITY NUMBER: 496803241
VISIT DATE: 08/13/2024
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Continued from 809...

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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