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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803339
Report Date: 01/29/2025
Date Signed: 01/29/2025 03:17:21 PM

Document Has Been Signed on 01/29/2025 03:17 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 PAULIN CREEKFACILITY NUMBER:
496803339
ADMINISTRATOR/
DIRECTOR:
ALVARADO, ROBERTFACILITY TYPE:
740
ADDRESS:2375 RANGE AVETELEPHONE:
(707) 575-3722
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 100TOTAL ENROLLED CHILDREN: 0CENSUS: 70DATE:
01/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Robert Alvarado, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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At approximately 8:45 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and met with Executive Director (ED), Robert Alvarado. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Fire clearance is approved for one hundred (100) non-ambulatory, of which twenty (20) may be bedridden. There is an approved hospice waiver for eighteen (18) residents. There is a large independent living population that rents apartment units on the property, these are not part of the Residential Care for the Elderly (RCFE) license. The facility has an emergency disaster plan as required. The facility has a required infection control plan. Upon arrival, LPA was informed that there were 45 residents in Assisted Living and 25 residents in Memory Care for a total of 70 residents in care. LPA reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation.

At 10:10 AM LPA toured the facility with ED Robert Alvarado. The facility was observed to be clean, orderly, and at a comfortable temperature during today's visit. All common areas, hallways, and bathrooms observed by the LPA had sufficient lighting. Bathrooms observed had grab bars, and non-slip mat/flooring for bathing/showering as needed. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. The facility offers a variety of menu options for the residents at each meal. Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products. All toxins/cleaners were locked and inaccessible to residents in care. Hot water temperatures for a sample size of 9 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. The call system was tested in two (2) resident's rooms and Caregiver response time was under one (1) minute for both instances.

Continued on 809-C...
Victoria BertozziTELEPHONE: (707) 588-5059
Robert FrankTELEPHONE: (707) 588-5026
DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 PAULIN CREEK
FACILITY NUMBER: 496803339
VISIT DATE: 01/29/2025
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...Continued from 809

Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected 12/31/2024. Fire Department inspection was completed on 1/7/2025. There were no violations noted. All exits were observed to be unobstructed. All fire extinguishers were last serviced and tagged on 10/8/2024. The last fire drill was conducted on 12/15/2024. The facility completes fire/emergency drills monthly.

At 11:45 AM, LPA conducted a sample file review of ten (10) staff members. All staff members had appropriate documentation, proof of training and current 1st Aid and CPR certification on file. LPA also conducted a sample file review for ten (10) residents. Upon review, LPA observed residents to have appropriate documentation on file including current Service Plans and Physician's Reports. All medications were locked and inaccessible to residents in care. LPA conducted a spot check of 4 memory care residents’ medications and observed all documentation and medications to be in order.

During the tour, residents were observed interacting with staff in common spaces, resting in their private bedrooms, participating in various activities with Activities Director and mingling in the dining hall and common areas with family and amongst each other. Residents interact with one another in the dining area, common spaces as well as in resident private apartments. The facility provides an eclectic range of activities specified for both assisted living and memory care engagement. There is a hair/beauty salon which is open 4 days a week. There is a small vineyard and vegetable garden where residents grow grapes and various flora.

Administrator/Executive Director, Robert Alvarado Administrator Certification #7017266740 is pending renewal. Application received on 8/14/2024.

LPA is requesting the following documents submitted to CCLD by 2/27/2025:



LIC500 - Personnel Report
Copy of Current Liability Insurance

No deficiencies cited during today's visit. Exit interview conducted. Copy of report discussed and provided to ED Robert Alvarado. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Robert FrankTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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