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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803339
Report Date: 12/21/2022
Date Signed: 12/21/2022 04:09:04 PM


Document Has Been Signed on 12/21/2022 04:09 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: 61DATE:
12/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Robert Alvardo-AdministratorTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) conducted a Required 1 Year Inspection on 12/21/22 at approximately 1:00pm; LPA met with Administrator Robert Alvarado, and Shelby Beem, H&W Director. The inspection is focused on the infection control procedures and practices of this facility.

The LPA reviewed some resident reports to obtain more information.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for ten (10) residents. Fire clearance is approved for 120 nonambulatory,, of which 20 may be bedridden. Fire clearance also approves delayed egress. Fire extinguishers were tagged and inspected as required- 10/7/2022. Administrator has submitted facility's required Infection Control Plan.

Facility building was found to be clean, and at a comfortable temperature with all exits free from obstruction. Facility has a sufficient supply of personal protective equipment(PPE) in both the assisted living, and memory care areas. Administrator and all staff observed during the inspection were wearing masks as required. Food supply was sufficient. All medications and toxins/cleaners were all locked and inaccessible to residents in care.

No deficiencies found in the areas inspected.
No citations issued.
Exit interview conducted with the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
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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