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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803339
Report Date: 02/13/2025
Date Signed: 02/13/2025 01:03:23 PM

Document Has Been Signed on 02/13/2025 01:03 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: DATE:
02/13/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Robeert Alvarado-AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Alvisoa conducted a case management inspection and met with Robert Alvarado, Administrator.

The purpose of today's case management was to follow up on a facility self reported resident incidents regarding medication errors. In review of records, R1 and R2 both had medication error incidents occur. Per review of records, the medication staff had in-service training on medication policies in regards to medication assistance to residents in care. Information obtained support that a violation had occurred regarding both resident incidents.

This deficiency will be cited, 87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22 of California Regulation.
Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator Robert Alvarado.
Appeal rights provided.
Bethany MoellersTELEPHONE: (707) 588-5040
Dina AlvisoTELEPHONE: (707) 588-5082
DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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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Document Has Been Signed on 02/13/2025 01:03 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2025
Section Cited
CCR
87465(a)(4)

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87465(a)(4) Incidental Medical and Dental Care- A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed, This requirement was not met as evidenced by: In review of records, R1 and R2 both had medication error incidents occur.
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POC CLEARED- LICENSEE/ADMINISTRATOR HELD AN IN-SERVICE MEDICATION POLICIES TRAINING WITH MEDICATION STAFF. ADMINISTRATOR PROVIDED COPIES TO THE LPA.
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Per review of records, the medication staff had in-service training on medication policies in regards to medication assistance to residents in care. Information obtained support that a violation had occurred regarding both resident incidents. This is a risk to residents health &safety.
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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.
Bethany MoellersTELEPHONE: (707) 588-5040
Dina AlvisoTELEPHONE: (707) 588-5082

DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025

LIC809 (FAS) - (06/04)
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