<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803339
Report Date: 12/11/2023
Date Signed: 12/11/2023 05:33:14 PM


Document Has Been Signed on 12/11/2023 05:33 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:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Robert Alvarado-AdministratorTIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst(LPA) Alviso conducted Required-1 Year inspection, on 12/11/23 at approximately 3:10pm, 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.

The facility had all observed exits unobstructed. All fire extinguishers were serviced and tagged 10/23/23, as required. LPA toured the kitchen. LPA toured the memory care unit.

The Department will continue this inspection at a later date.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1