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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803241
Report Date: 07/27/2022
Date Signed: 07/27/2022 03:05:26 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
06/28/2022 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20220628170655
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: 87DATE:
07/27/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Maria CortesTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Lack of supervision resulting in resident eloping from facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis arrived unannounced to deliver findings regarding the above complaint allegation and met with Administrator, Maria Cortes.

During investigation LPA conducted interviews, reviewed documents and made observations.

Lack of supervision resulting in resident eloping from facility – Complaint alleges that a resident who is unable to be in the community unassisted eloped the facility. Interviews with involved parties and review of documents revealed that resident eloped the facility without staff knowledge and was not found until approximately three hours later by local law enforcement. Per interview, a delayed egress door in Memory Care was knowingly malfunctioning requiring staff to manually arm the alarm for it each time someone attempted to exit. Interview and review of facility exit logs suggests that resident eloped the facility through this door.

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: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
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 3
Control Number 21-AS-20220628170655
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: 07/27/2022
NARRATIVE
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Continued from LIC9099

Staff observed that resident was not in their room at approximately 6:20am but assumed that the resident was elsewhere in the unit. Later in the morning, the resident was observed to be missing. Per facility protocol, the Memory Care Unit was searched and then the entire facility. Per police report, local law enforcement was dispatched to the facility at 9:32am. Resident was found approximately 2.5 miles away around 10:20am by a community member who contacted the police. Report notes that resident was having a difficult time walking and was taken to the hospital for leg pain. Once at the hospital, R1 was diagnosed with a stress fracture.

An immediate civil penalty in the amount of $500.00 is issued today for the violation of a regulation resulting in bodily injury or illness of a person in care. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code 1569.49(f). At this time, the civil penalty assessment is under review.

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: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20220628170655
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: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2022
Section Cited
CCR
87705(j)
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87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement has not been met as evidenced by interview and document review showing that resident eloped the facility despite not being
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Administrator agrees to submit the updated elopement protocol, which they have updated due to this incident to CCL by POC due date, 7/28/2022.
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able to be in the community by themselves. This is an immediate risk to the health and safety nof residents in care.
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An immediate civil penalty in the amount of $500.00 is issued today for the violation of a regulation resulting in bodily injury or illness of a person 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: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3