496803339-4-24-2024-21-AS-BMOS-D53V5U-20240508160830

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803339
Report Date: 04/24/2024
Date Signed: 04/24/2024 05:02:31 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
01/19/2024 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240119140417

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:	04/24/2024
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Robert Alvarado-Administrator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff do not provide adequate activities for residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 4/24/24, at approximately 2:10pm, and met with Robert Alvarado Administrator/Executive Director.

LPA reviewed facility records, and interviewed staff and other related parties regarding the allegation. Reporting party alleges that "staff do not provide adequate activities for residents". LPA reviewed the activity calendars for the memory care unit, for December 2023, and January 2024. LPA requested documentation showing which activities were actually held in memory care back in December 2023, and January 2024. Administrator was not able to provide completed records of activities that were actually held, provided daily to residents, in the memory care unit. The Administrator notified the LPA on 1/23/24 that there was not an activity director working at this time, and they have been trying to hire someone for the position. The caregivers in memory care have been helping when able to provide some activities to the memory care residents.

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: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240119140417

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: 04/24/2024

NARRATIVE

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The LPA reviewed information obtained from an Agency that while on site at the facility 12/12/23, they were not doing the posted activities. They were told they were hiring someone to oversee the activities in memory care.

Currently there is an activity program coordinator hired as of 1/31/24. The new activity program coordinator will be documenting all activities held daily, and documenting any changes to the activities scheduled, including posting the changes to keep all residents, and others updated as required. The Activity Program Coordinator provided copies to the LPA of how activities are being documented.

Based on LPA interviews, and review of records, and information obtained, the facility had no supportive documentation to show which activities were being held and/or not being held; The facility didn't have a staff hired as the Activity Director, who was the dedicated staff person in charge of the facility's resident activity program only. The memory care unit had no accurate activity records and/or updates of the activity calendar. The investigation has revealed that the allegation of "staff do not provide adequate activities for residents " in the memory care unit, has been Substantiated.

Due to the substantiation of the allegation, a citation, Planned Activities 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.

Exit interview held with the Administrator Robert Alvarado.
Appeal Rights provided.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240119140417

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: 04/24/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/03/2024 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.	1 2 3 4 5 6 7	POC CLEARED- Administrator has hired an Activity Program Coordinator as of 1/31/24; The Activity Program Coordinator is documenting daily activities held. The calendar is being kept up-to-date when activities are changed for any reason, these are posted up for residents/for all others.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on LPA's investigation, the facility had no supportive documentation to show which activities were being held and/or not being held; The facility didn't have a staff hired as the Activity Director, who was the dedicated staff person in charge of the facility's resident activity program only. The memory care unit had no accurate activity records and/or updates of the activity calendar. This is a personal rights risk to residents in care.	8 9 10 11 12 13 14	Activities are being held regularly in the memory care unit at this time. Activity records are being maintained as needed. Documentation, and written plan of correction was provided. POC is cleared 4/24/24.
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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: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC9099 (FAS) - (06/04)

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