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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803241
Report Date: 11/15/2024
Date Signed: 11/15/2024 05:48:21 PM

Document Has Been Signed on 11/15/2024 05:48 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BROOKDALE CHANATEFACILITY NUMBER:
496803241
ADMINISTRATOR/
DIRECTOR:		ORDING,KELLYFACILITY TYPE:
740
ADDRESS:3250 CHANATE RDTELEPHONE:
(707) 575-7503
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 140TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
11/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:36 PM
MET WITH:Sales Manager, Karin BerryTIME VISIT/
INSPECTION COMPLETED:
06:02 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to open a compliant investigation at this facility.

Upon LPA arrival LPA was informed that there was not an Administrator present at the facility. The Administrator of record, Kelly Ording is no longer employed by Brookdale but LPA was advised there is an Interim Administrator (IA), Jannluy Trevino. LPA reached IA by phone to advise of LPA's visit to facility and to inquire as to the status of an Administrator. IA advised that there are candidates being considered. IA advised that they work remotely as they live out of state, but that they are also present in-person at the facility.

LPA contacted CCL Santa Rosa Regional Office (RO) to confirm IA has an active current Administrator certificate. All three Administrator certificate databases were searched: Active certificates, Pending initial certificates, and Pending renewal certificates, IA was not found. Additionally, fingerprint clearance and association to the facility could not be confirmed. Per RO, IA does not show as having fingerprint clearance and is not currently present on the facility roster (deficiency cited, see 809D **civil penalty assessed**).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Sales Manager. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Sales Manager and a copy of this report was given.
Victoria BertozziTELEPHONE: (707) 588-5059
Christi CoppoTELEPHONE: (707) 588-5054
DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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Document Has Been Signed on 11/15/2024 05:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: BROOKDALE CHANATE
FACILITY NUMBER: 496803241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted. Licensee did not meet this requirement as evidenced by; interim administrator does not have fingerprint clearance.
Deficient Practice Statement
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POC Due Date: 11/18/2024
Plan of Correction
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Interim Administrator to submit LIC9098 by plan of correction due date, indicating they will not be present or working at the facility, and will not return to the facility until after they have obtained fingerprint clearance, is associated to facility, and submited proof of required clearance and association to CCL.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria BertozziTELEPHONE: (707) 588-5059
Christi CoppoTELEPHONE: (707) 588-5054

DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024

LIC809 (FAS) - (06/04)
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