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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803241
Report Date: 10/19/2022
Date Signed: 10/19/2022 03:34:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
07/26/2022 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20220726153617
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: 78DATE:
10/19/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Maria CortesTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff are not responding to call buttons
INVESTIGATION FINDINGS:
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Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegation and met with Administrator, Maria Cortes.

Staff are not responding to call buttons – Complaint alleges that caregivers are not responding to call buttons resulting in resident having to call outside individuals and 911. Per interviews, facility does not have a designated timeframe of when call buttons are to be responded to but staff are directed to respond timely and if they are unable to respond timely, they are to request help from another staff. Review of call logs for resident, R1 over a fifteen-day period showed that out of 125 calls, 42 of them were responded to 15 minutes or later and 6 were not responded to.

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

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
07/26/2022 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20220726153617

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: 78DATE:
10/19/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Maria CortesTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff left resident soiled in urine and feces causing resident to have a rash and UTI
Staff did not maintain residents hygiene
Resident not administered medication as prescribed
Resident’s laundry was missing
INVESTIGATION FINDINGS:
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Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegation and met with Administrator, Maria Cortes.

Staff left resident soiled in urine and feces causing resident to have a rash and UTI – Complaint alleges that resident was not assisted with their incontinence needs. Per review of medical records, resident was diagnosed with a UTI but a rash was not mentioned. Interviews provided conflicting reports of whether resident had a rash before moving into the facility. Service Plan dated 6/8/2022 notes that there are no open areas and skin is intact. LPA was unable to confirm through evidence that resident had a UTI and rash as a result of allegedly being left in soiled incontinence briefs.

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

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
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-20220726153617
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/19/2022
NARRATIVE
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Continued from LIC9099

Staff did not maintain resident’s hygiene - Complaint alleges that resident was not bathed during their stay in the facility. Interview with involved individual indicated that showers were not requested by the resident or offered by staff. Per staff interviews and progress notes, resident refused showers. Two staff recalled resident receiving a sponge bath during their stay.

Resident not administered medication as prescribed – Complaint alleges that resident was not given reminders by staff to take their medication and stay with resident until their medications were taken. Per Resident’s physician’s report, resident was able to store and administer their own medication. Per staff interviews, the medication was stored in R1’s room and staff would bring the medication to the resident where R1 administered it themselves. Interview with involved resident indicated that staff administered their injectable medication, but staff denied this. Per the Personal Service Assessment dated 5/20/2022 staff attention or physical assistance while taking medications is needed however it goes on to indicate that resident does not need staff attention during administration of injectable medication, does not need staff to administer injection or supervise or perform blood sugar monitoring.

Resident’s laundry was missing – Complaint alleges that the resident’s laundry went missing for multiple days, including their bed linens. Interviews indicate that a basket of clothes was picked up by the laundry staff because they assumed it was dirty clothes as the clothes were unfolded. Per interviews, the clothes were returned by the following day. Staff interviews do not recall a time when resident did not have linens on their bed and indicate laundry is completed within 24 hours.

A finding that the complaint allegations staff left resident soiled in urine and feces causing resident to have a rash and UTI, staff did not maintain resident’s hygiene, resident not administered medication as prescribed and resident’s laundry was missing were unsubstantiated meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegation occurred.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20220726153617
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/19/2022
NARRATIVE
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Continued from LIC9099

The allegation that Staff are not responding to call buttons 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 BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20220726153617
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2022
Section Cited
CCR
87303(i)(1)
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Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory
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Per discussion with Administrator, they will be adding a Quality Assurance componennt to ensure compliance and will submit more a detailed plan to CCL in writing to CCL by POC due date, 10/20/2022.
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signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit Requirement has not been met based on review of review of call logs for resident over a f15 day period showing that out of 125 calls, 42 of them were responded to 15 minutes or later and 6 were not responded to. This is am immediate risk to health and safety.
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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 BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5