496803339-11-3-2022-21-AS-CMAZ-CNH2QN-20230127163612

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803339
Report Date: 11/03/2022
Date Signed: 11/03/2022 02:47:43 PM

Unsubstantiated

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
10/04/2022 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20221004085445

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: 58	DATE:	11/03/2022
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Robert Alvarado-Administrator		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff did not address resident's death in a timely manner
Resident was not accorded dignity while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 11/3/22 at approximately 10:20am, and met with Robert Alvarado Administrator/ED, and Shelby Beem, H&W Director. LPA reviewed resident file documents, resident death reports, and faciliy file documents, including staff trainings; The LPA contacted and interviewed numerous staff regarding the allegations. The investigation revealed that there was no identifying information of residents and/or staff provided by reporting party(s) regarding the filed allegations; The LPA was not able to obtain any information and/or documentation during the investigation to support the above allegations.
Based on record reviews, interviews conducted, and information obtained, there is no evidence to support the violations occurred. The allegations of "Staff did not address resident's death in a timely manner" and "Resident was not accorded dignity while in care" 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.
No deficiencies cited during todays visit.
Exit interviews were conducted with Administrator Robert Alvarado

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: 11/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022

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

LIC9099 (FAS) - (06/04)

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