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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496802025
Report Date: 05/30/2025
Date Signed: 05/30/2025 11:45:58 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
02/05/2025 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20250205134706
FACILITY NAME:BROOKDALE WINDSORFACILITY NUMBER:
496802025
ADMINISTRATOR:KINNEY, JEANNETTEFACILITY TYPE:
740
ADDRESS:907 ADELE DRTELEPHONE:
(707) 837-8785
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:80CENSUS: DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Jeanette Kinney, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff did not seek timely medical care for resident
Facility staff did not ensure resident’s room was maintained clean
Facility staff did not provide explanation of services to be provided at the new level of care to resident's responsible person
Facility staff did not provide an itemization of charges to resident's responsible person
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegations and met with Jeanette Kinney, Administrator.

Complaint alleges facility staff did not seek timely medical care for resident. Complainant alleges that resident (R1) fell in their room resulting in head injury but facility did not seek medical attention. During investigation, LPA reviewed chart notes of R1. Chart notes indicate that R1 was found at 0800 laying on the floor, they had hit their head on the shower floor. A head bandage was applied by staff and pain medication administered at 0856. R1’s elbow had a hematoma forming and their bottom area was not examined due to the immediate attention their head needed. Hospice was notified 3 times: an initial call, a follow up call, and a third call to see if the facility should send the resident out to the ER. Notes indicate the bleeding from R1’s head was not stopping, despite keeping pressure to the back right side of their

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 21-AS-20250205134706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 WINDSOR
FACILITY NUMBER: 496802025
VISIT DATE: 05/30/2025
NARRATIVE
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Continued from 9099...

head. Case Manager arrived at the facility at 0945 advising facility that hospice was on the way. After hospice team arrived, they made the decision to have R1 sent to the ER by ambulance. LPA’s review of chart notes indicate that R1 experienced an injury unrelated to the reasons for which they were on hospice. However, facility waited almost 2 hours, with R1’s head continuously bleeding, before sending to the hospital. Additionally, the facility waited for hospice to make the determination to send to the hospital, they themselves did not make the determination. Based on LPA’s record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Complaint alleges facility staff did not ensure resident’s room was maintained clean. Complainant alleges facility did not properly clean R2’s room and that remnants of fecal incontinence were left unattended. During investigation, LPA reviewed Administrator’s email pertaining to the cleaning of R2’s room, email shows that Administrator acknowledged that staff needs to “clean things up much better.” Additionally, in email, Administrator acknowledges that “if maintenance is not available to clean up, then the facility needs to find another person that can clean up right away.” Based on LPA’s record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Complaint alleges facility staff did not provide notification of or explanation of services to be provided at the new level of care to resident's responsible person and that facility staff did not provide an itemization of charges to resident's responsible person. During investigation, LPA reviewed billing statements provided to R2’s responsible party from the facility. LPA also reviewed email exchange between facility’s Health and Wellness Director (HWD) and R2’s responsible party. Increase in charges for new level of care were implemented January 1, 2025. However, R2’s responsible party claims they were not made aware of the changes in level of care needed nor that a new level of care was being provided. LPA reviewed R2's three most recent care plans and found care plan from December 24, 2024 to indicate increased level of care needed for R2. However, none of the care plans were signed by R2’s responsible party. Facility did eventually provide

Continued on 9099C(2)...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 21-AS-20250205134706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 WINDSOR
FACILITY NUMBER: 496802025
VISIT DATE: 05/30/2025
NARRATIVE
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Continued from 9099C...

explanation of fees and itemization of fees to resident’s responsible party on January 26, 2025. However, facility could not show or provide LPA with proof of initial notification. Per Health and Safety Code 1569.657(a), any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. However, facility could not provide LPA proof of notification sent to R2's responsible party within two [2] business days after initially providing services at the new level of care. Based on LPA’s record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

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 Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 21-AS-20250205134706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 WINDSOR
FACILITY NUMBER: 496802025
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2025
Section Cited
CCR
87469(c)(3)
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87469 Advanced Directives and Requests Regarding Resuscitative Measures (c) If a resident...experiences a medical emergency, facility staff shall do one of the following: (3) Specifically for a terminally ill resident that is receiving hospice services...and is experiencing a life-threatening emergency...
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Facility to submit plan to conduct in-service hospice care and emergency procedures training for all direct care staff and Med Techs in the amount of no less than 1 hour by plan of correction due date. Facility to complete training for all direct care staff and Med Techs no later than 6/20/25. Completed training sign in sheet to be sent to CCL by no later than 6/20/25.
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not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). This requirement is not met as evidenced by: Based on LPA’s record review, the licensee did not comply with the section cited above in that facility did not immediately telephone emergency response for R1’s injury that was not directly related to the expected course of the resident’s terminal illness, which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
06/06/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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Facility to submit LIC9098 self-certifying all resident rooms will be kept in clean, safe, and sanitary conditions and that sufficient staff will be on duty to ensure as such.
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as evidenced by:
Based on LPA’s record review, the licensee did not comply with the section cited above in that facility did not properly R2’s room, which poses an immediate health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 21-AS-20250205134706
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 WINDSOR
FACILITY NUMBER: 496802025
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2025
Section Cited
HSC
1569.657(a)
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§1569.657 Rate increase due to change in level of resident care; notice (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing
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Facility to submit LIC9098 self-certifying that they will notify in writing residents' or residents' responsible party within 2 days of any change of level of care needs cost by plan of corrections due date.
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services at the new level of care... This requirement is not met as evidenced by: Based on LPA’s record review and interview, the licensee did not comply with the section cited above in that facility did not provide R2’s responsible party written notice of rate increase within two business days after initially providing services at the new level of care which poses an potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7