496803339-8-15-2023-21-AS-BMOS-CV7TBD-20230830143457

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803339
Report Date: 08/15/2023
Date Signed: 08/15/2023 10:19:30 AM

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
08/11/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230811144525

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: 57	DATE:	08/15/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Robert Alvarado-Administrator		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Staff stole resident’s belongings
Resident’s shower is in disrepair
Staff did not provide resident with an admissions agreement
Staff does not post Ombudsman poster

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 8/15/2023 at approximately 9:15am, and met with the Administrator Robert Alvarado. LPA requested resident (R1) records to review regarding the allegations listed above. The investigation revealed that resident (R1) is not a resident of the assisted living residential care facility for the elderly-license #496803339.The facility is an assisted living community, which includes a dementia unit;There are independent living units on the property that are not part of the licensed assisted living. The independent living units are rented/leased out to independent individuals. Independent living residents do not receive the care services and supervision that is required as part of residing in the assisted living. LPA observed a lease agreement signed by resident (R1), on 10/31/2022, for an independent living unit. The allegations of, Staff stole resident’s belongings, Resident’s shower is in disrepair, Staff did not provide resident with an admissions agreement, Staff does not post Ombudsman poster, are Unfounded, the Department has no jurisdiction over the independent living portion of Brookdale Paulin Creek.

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: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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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