496803339-2-16-2022-21-AS-HDBI-CCHVLT-20220314163226

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803339
Report Date: 02/16/2022
Date Signed: 02/16/2022 05:22:27 PM

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
02/10/2022 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220210151418

FACILITY NAME:	BROOKDALE PAULIN CREEK		FACILITY NUMBER:	496803339
ADMINISTRATOR:	ALVARADO, ROBERT		FACILITY TYPE:	740
ADDRESS:	2375 RANGE AVE		TELEPHONE:	(707) 575-3722
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	100	CENSUS:	DATE:	02/16/2022
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Robert Alvarado-Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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No activities being provided to memory care residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Dina Alviso, met with Administrator Robert Alvarado, and conducted a complaint inspection, on February 16, 2022, at approximately 10:50am, to address the above allegation.

LPA conducted interview(s), and requested specific activity documentation, regarding memory care activities. The Administrator provided the December 2021, and January 2022, activity calendars for the memory care unit. Administrator stated that he had some issues with having a Program Director for awhile but that he does have the position filled now. LPA had requested activity documentation of all activities held, and documentation of any changes to the scheduled daily activities, any activity documentation to show what activities were provided and which activities were not and why.

LPA asked specifically for the following dates documentation: Scheduled morning activities, two(2) scheduled in the am, on 12/3, 12/10, 12/14 of 2021, and 1/14/2022. The Administrator stated that he would try to obtain facility documentation but when returning to meet with the LPA the Administrator could not provide any proof and/or activity documentation of any kind, aside from the monthly calendar that is sent out each month, LPA was provided a copy of December 2021, and January 2022.
Continued on LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

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-20220210151418

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 PAULIN CREEK	FACILITY NUMBER: 496803339
	VISIT DATE: 02/16/2022

NARRATIVE

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The Administrator stated the activities on 12/3/21 & 12/10/21 did not happen based on the activity directors schedule, they were off on Fridays, and he does not know if another staff provided the activities; The Administrator stated he does not know if activities were held on 12/14/21 and he does not have any records on activities but the calendar with scheduled activities listed. LPA observed that 1/14/22 is also a Friday. The Administrator stated that the activity may have been changed to just count the day the pet dog is brought into the building to visit with residents but the Administrator had no documentation to show any activity changes made to the calendar, and per interview(s) no residents have received any updated record and/or calendar of activity changes being made to the schedule. No updates to the schedule and/or changes, nothing could be provided to the LPA from the Administrator in regards to the activity schedule/calendar. LPA reviewed the planned activities regulation 87219, with the Administrator. The Administrator stated that he would be instituting a document to be used by the Activity Director and activity staff, to document activity information as needed and required per regulation.

Per LPA interview(s), record reviews, there was no facility supportive documentation to show activities were provided as scheduled on the specified days and time and/or documentation of any changes to the activity schedule. The LPA reviewed a declaration from an Agency staff person that was received by CCL, this Agency staff was on-site at the facility and observed no activities being held the morning of 12/3/21, 12/10,21, 12/1421, and 1/14/21 as scheduled on the am activity calendar.
Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation of "no activities being provided to memory care residents" on the specified days in this report, has been Substantiated.

Due to the substantiation of the allegation, a citation, 87219(a)(f), will be cited today-see LIC9099D.
The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.
Appeal Rights Given.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20220210151418

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 PAULIN CREEK	FACILITY NUMBER: 496803339
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/25/2022 Section Cited CCR 87219(a)(f)	1 2 3 4 5 6 7	87219 (a)(f) Planned Activities- in facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. The program of activities shall be written, planned in advance, kept up-to-date, and made available to all residents. The responsible employee shall have had at least one year of experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers.	1 2 3 4 5 6 7	The Licensee/Administrator to ensure that activities are being provided as required by regulation and facility's plan of operation. Administrator to ensure the Activity Calendar is kept up to date, provided to residents, and any changes to the activity schedule are noted and documented as required by regulation.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by the LPA's review of records, interviews with staff, and other related parties. The Administrator could not provide any facility activity records regarding the Activity calendar if there have been any changes and/or if activities occurred as planned. This is a potential risk to the personal rights of all residents in memory care,	8 9 10 11 12 13 14	The Administrator to submit the facility's plan to correct this violation and bring the facility activity schedule process/procedures and maintaining records bringing facility into compliance. Submit plan of correction by 2/25/22.
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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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

LIC9099 (FAS) - (06/04)

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