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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803241
Report Date: 12/27/2024
Date Signed: 12/27/2024 01:08:19 PM

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
12/17/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20241217154914
FACILITY NAME:BROOKDALE CHANATEFACILITY NUMBER:
496803241
ADMINISTRATOR:ALVARADO, ROBERTFACILITY TYPE:
740
ADDRESS:3250 CHANATE RDTELEPHONE:
(707) 575-7503
CITY:SANTA ROSASTATE: ZIP CODE:
95404
CAPACITY:140CENSUS: DATE:
12/27/2024
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Robert Alvarado, AdminTIME COMPLETED:
01:22 PM
ALLEGATION(S):
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Licensee failed to administer medications as prescribed by physician
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegations. LPA met with Robert Alvarado, Administrator.

Complaint alleges licensee failed to administer medications as prescribed by physician

During investigation, LPA reviewed resident's (R1) physician's orders, electronic MAR (eMAR), and Medication Administration Audit report. R1's medication list as of 11/25/24 listed Sevelamer Carbonate 800mg 1 tablet 3 times per day. R1 was discharged from a hospital stay on 12/6/24. LPA review of 12/6/24 discharge papers have medication orders for Sevelamer 800mg 1 tablet 3 times per day.


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

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
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 3
Control Number 21-AS-20241217154914
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 CHANATE
FACILITY NUMBER: 496803241
VISIT DATE: 12/27/2024
NARRATIVE
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Continued from 9099...

However, review of facility's Medication Administration Audit report and eMAR system indicates R1 had been receiving Sevelamer Carbonate 800mg 3 tablets 3 times per day from 11/27/24 through 12/16/24.

On 12/17/24 R1's Sevelamer dosing was changed to 800mg 1 tablet 3 times per day. LPA review of facility's eMAR shows that on 12/16/24 the Sevelamer Carbonate 800mg 3 tablets 3 times per day was discontinued. However, CCL was never informed of the medication error and has never received an Incident report for the medication error (deficiency cited, see 9099D).

LPA's review of R1's discharge papers, medications list of current prescriptions, and facility's eMAR all show that R1 received the incorrect dose of Sevelamar between the dates of 11/27/24 and 12/16/24. Therefore, based on LPA's record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

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: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20241217154914
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 CHANATE
FACILITY NUMBER: 496803241
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met by licensee as evidenced by:
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Facility has discontinued incorrect prescription dose for R1 and implemented dosing that matches physician's orders for R1. Facility to submit plan to conduct training for all Med Techs on ensuring the reisdent's current medications on eMAR
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Based on LPA record review, R1 received the incorrect dosing of Sevelamer from 11/27/24 through 12/16/24, which poses an immediate health, safety or personal rights risk to persons in care.
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match respective residents' physician's orders by plan of correction due date. Proof of training to be submitted to CCL no later than 1/3/25
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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: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3