496803339-12-11-2023-21-AS-BMOS-D32PFP-20240304101705

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803339
Report Date: 12/11/2023
Date Signed: 12/11/2023 05:29:08 PM

Unfounded

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
11/15/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20231115115708

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: 68	DATE:	12/11/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Viola Kaake, Associate Executive Director		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff did not provide resident transportation to medical appointments

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 12/11/2023, at approximately 9:40am, and met with Viola Kaake, Associate Executive Director (ED). Director Viola contacted Executive Director/Administrator Robert Alvarado. Administrator stated they would be arriving to the facility to meet with the LPA.

LPA reviewed resident records, R1/R2, and obtained copies of requested documents, including account/financial records, admission agreements, care plan services, resident handbook regarding transportation services (obtained copy), and records on any maintenance repairs to apartment unit.

LPA reviewed the facility's bus schedule, operating days and hours (obtained copy. LPA reviewed obtained information from reporting party LPA conducted interviews with staff, S1 & S3, and other related parties.

Continued on LIC9099C...

Unfounded

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: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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 4

Control Number 21-AS-20231115115708

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: 12/11/2023

NARRATIVE

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The investigation revealed that the facility has a bus schedule for transportation available on specific days and hours, for Doctor Appointments, Pharmacy, and Bank as follows: Tuesday, Wednesday, and Thursday from 8:15am- 9:15am- 10:15am- 11:15am- 1:15pm- 2:15pm- with last pick-up at 3:30pm. Fridays bus schedule is 8:15am- 9:15am- 10:15am- 11:15am- with last pick-up at 12:15pm. The resident admission agreement states, Transportation- The Community will provide scheduled transportation for shopping and for other errands and planned social events in and around the local area- the facility bus schedule. The resident handbook provides additional transportation guidelines, resident handbook states "Most communities offer scheduled transportation to stores and doctor appointments within a designated service area. We can help make arrangements if you need transportation outside of our regular schedule or service area. The LPA reviewed emails and video that were related to the complaint investigation. Per review of records and information obtained, R1 had Doctor appointments that started at 8am, three times a week, and R2 provided transportation to R1 to get to the medical appointments. The facility bus schedule doesn't start before 8:15am; There was no request to the facility to help arrange other transportation, which would be at the cost of the resident. Admission agreement, resident handbook, and per emails reviewed, the transportation information was provided to all parties. There was no information supporting a violation had occurred.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation of "staff did not provide resident transportation to medical appointments" is Unfounded.
The Department has found that the complaint allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted with the Administrator Robert Alvarado.
No deficiencies cited.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
11/15/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20231115115708

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:	12/11/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Viola Kaake, Associate Executive Director		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility was in disrepair
Staff charged residents for services not rendered

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 12/11/2023, at approximately 9:40am, and met with Viola Kaake, Associate Executive Director (ED). Director Viola contacted Executive Director/Administrator Robert Alvarado. Administrator stated they would be arriving to the facility to meet with the LPA.

LPA reviewed resident records, R1/R2, and obtained copies of requested documents, including account/financial records, admission agreements, care plan services, resident handbook regarding transportation services (obtained copy), and records on any maintenance repairs to apartment unit. LPA reviewed the facility's bus schedule, operating days and hours (obtained copy. LPA reviewed obtained information from reporting party LPA conducted interviews with staff, S1 & S3, and other related parties.

Continued on LIC9099C...

Unsubstantiated

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: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20231115115708

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: 12/11/2023

NARRATIVE

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The investigation revealed that the resident apartment did have an air-conditioner that had a leak. Per record reviews, emails, and interviews with staff and other related parties. the investigation revealed that the air-conditioner had to be repaired, and a part was ordered; The facility provided a portable air-conditioner in the apartment until the unit's air conditioner was repaired. Per the investigation of records and interviews, It is unknown if the portable air-conditioner also leaked. The unit's air-conditioner was repaired when the facility received the part needed. There was differing information obtained during the investigation regarding the allegation.

The investigation revealed that financial records showed that there were fees that were credited to the residents account by facility choice after discussions back and forth with other party, per records/interviews. Per investigation, there was no information obtained to support a violation occurred regarding resident care services being provided and/or fees for care charged in error.

Some fees that were due to be refunded, were put to outstanding fees owed to the facility for care services and tray service. The remainder of the refund, $122.15 was provided to residents/responsible party as required. There was differing information obtained during the investigation regarding the allegation.

Based on record reviews, interviews conducted, and information obtained, there is no evidence to support the violations occurred. The allegations of "facility was in disrepair, staff charged residents for services not rendered" are UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Exit interviews were conducted with Administrator Robert Alvarado
No deficiencies cited.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4