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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803339
Report Date: 01/09/2024
Date Signed: 01/09/2024 05:47:16 PM

Document Has Been Signed on 01/09/2024 05:47 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BROOKDALE PAULIN CREEKFACILITY NUMBER:
496803339
ADMINISTRATOR:ALVARADO, ROBERTFACILITY TYPE:
740
ADDRESS:2375 RANGE AVETELEPHONE:
(707) 575-3722
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 100CENSUS: 68DATE:
01/09/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Robert Alvarado-AdministratorTIME COMPLETED:
06:00 PM
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Licensing Program Analyst(LPA) Alviso conducted a continued annual inspection, on 1/9/24 at approximately 2:45pm, and met Administrator Robert Alvarado.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for eighteen (18) residents. Fire clearance is approved for one hundred (100) non-ambulatory, of which twenty (20) may be bedridden. The facility has an emergency disaster plan as required. The facility has a required infection control plan.

LPA reviewed ten (10) resident files. Records were complete.
LPA reviewed ten (10) staff records. All staff have criminal record clearance as required by regulation. LPA reviewed staff training on file.

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. Facility has a sufficient supply of cleaners, hygiene items, PPE supply, and paper products.

All medications were locked and inaccessible to residents in care. All toxins/cleaners were locked and inaccessible to residents in care.

All exits were observed to be unobstructed. All fire extinguishers were serviced and tagged 10/23/23. The last fire drill was conducted 12/19/23; Facility completes fire/emergency drills monthly.

Continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BROOKDALE PAULIN CREEK
FACILITY NUMBER: 496803339
VISIT DATE: 01/09/2024
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LPA is requesting the following documents be updated and submitted by 2/9/24:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan -Submit if any changes and/or submit last page documenting annual review was completed.
Infection Control Plan- Submit if any changes and/or submit letter/ page documenting annual review was completed.
Copy of LIC400 Handling of Client Cash Resources, include copy of surety bond.
Copy of Current Liability Insurance
Copy of current Administrator Certificate

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

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
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