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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803241
Report Date: 12/09/2022
Date Signed: 12/09/2022 11:46:01 AM


Document Has Been Signed on 12/09/2022 11:46 AM - 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:CORTES, MARIAFACILITY TYPE:
740
ADDRESS:3250 CHANATE RDTELEPHONE:
(707) 575-7503
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:140CENSUS: 76DATE:
12/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator, Maria CortesTIME COMPLETED:
11:55 AM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Maria Cortes.

LPA is following up on three residents who passed away but were not on hospice.

Per report, resident R1 was sent to the hospital with complaints of shaking and not feeling normal. Per notes, resident had a slight fever, was coughing and stated that they were not feeling good. Resident was admitted to the hospital and diagnosed with the flu. Resident passed away while in the hospital.

Per report, resident R2 was sent to the hospital due to observed low oxygen where they passed away. Per review of documents, R2 had other health issues prior to being admitted to the hospital.

Per report, resident R3 was being escorted to breakfast when staff noted that resident was not responding. Staff returned resident to their room, administered oxygen and called 911. A police officer arrived and pronounced resident deceased.

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: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
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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