<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803241
Report Date: 02/16/2023
Date Signed: 02/16/2023 02:37:56 PM


Document Has Been Signed on 02/16/2023 02:37 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:CORTES, MARIAFACILITY TYPE:
740
ADDRESS:3250 CHANATE RDTELEPHONE:
(707) 575-7503
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:140CENSUS: 82DATE:
02/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Administrator, Maria CortesTIME COMPLETED:
02:47 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Administrator, Maria Cortes.

LPA is following up regarding the passing of resident, R1 who was not on hospice. LPA reviewed the resident's Certificate of Vital Record, their most recent Medical Assessment and other medical documentation.

LPA is also following up regarding a recent self-reported incident regarding resident, R2 and a family member. Facility reported per Mandatory Reporting requirements.

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: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1