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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803241
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:13:40 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
11/14/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20241114141725
FACILITY NAME:BROOKDALE CHANATEFACILITY NUMBER:
496803241
ADMINISTRATOR:ORDING,KELLYFACILITY TYPE:
740
ADDRESS:3250 CHANATE RDTELEPHONE:
(707) 575-7503
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:140CENSUS: DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Robert Alvardo, Acting AdministratorTIME COMPLETED:
03:28 PM
ALLEGATION(S):
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Facility did not provide resident's authorized representative with the correct refund
Facility billed resident's authorized representative after resident's departure from facility for incontinence items
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings for the above allegations. LPA met with Robert Alvarado, Administrator.

Compliant alleges facility did not provide resident's authorized representative with the correct refund. Per R1’s admission agreement, the agreement will terminate upon death. The estate will be responsible for all outstanding fees due at the time of death until personal property is removed from the Brookdale apartment, within 15 days after the personal property is removed from the apartment, R1’s estate will receive a refund of any fees paid in advance. LPA review of Brookdale’s account history for R1 shows that on 7/3/24 R1’s responsible party paid the full amount of rent covering the period of 7/1/24-7/31/24. During investigation, LPA received proof of the removal of R1’s personal belongings on 7/10/24 as evidenced by the paid invoice from removal company. R1 passed away on 7/13/24.

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

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
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 5
Control Number 21-AS-20241114141725
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: 01/09/2025
NARRATIVE
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Continued from 9099...

Therefore, the refund provided to R1’s responsible party should have been from 7/11/24-7/31/24, or at least 7/14/24-7/31/24. However, per review of R1’s account history report, the refund issued was for the period covering 7/21/24-7/31/24. So, 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. *Per LPA interview with Admin additional 7 rent days in question has been refunded to the responsible party as of 1/7/25.**

Complaint alleges facility billed resident's authorized representative after resident's departure from facility for incontinence items. On 5/27/24 R1 was hospitalized and subsequently never returned to Brookdale. During investigation, LPA reviewed R1’s account history report. Review shows that on 7/16/24 R1’s responsible party was billed three [3] charges of $102.50 for the dates of 6/15/24, 7/2/24, and 7/16/24. Per LPA interview with Administrator, these billings were in error and on 1/2/25 Brookdale refunded R1’s responsible party $307.50 for the aforementioned “personal solutions” fees. So, based on LPA’s record review and interview 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: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/14/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20241114141725

FACILITY NAME:BROOKDALE CHANATEFACILITY NUMBER:
496803241
ADMINISTRATOR:ORDING,KELLYFACILITY TYPE:
740
ADDRESS:3250 CHANATE RDTELEPHONE:
(707) 575-7503
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:140CENSUS: DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Robert Alvardo, Acting AdministratorTIME COMPLETED:
03:28 PM
ALLEGATION(S):
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Facility did not return resident's rented wheelchair to resident's authorized party
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings for the above allegations. LPA met with Robert Alvarado, Administrator.

Complaint alleges facility did not return resident's rented wheelchair to resident's authorized party. Reporting party alleges that the facility did not return a wheelchair belonging to Apria Healthcare. Allegedly, a wheelchair was dropped off by Apria for R1 at the facility on 5/26/24 to the Memory Care Unit. On 5/27/24 R1 was hospitalized and subsequently never returned to the facility. However, during investigation LPA was informed by centralized Apria customer service representative that a signed service rental agreement (SRA) was not on file for R1’s wheelchair. Per Apria customer service representative, if a wheelchair were to have been dropped off at the facility for R1, Apria would have a signed SRA on file.

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

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20241114141725
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: 01/09/2025
NARRATIVE
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Continued from 9099A...

However, neither the Apria centralized billing department nor the local branch had a signed SRA on file, nor could either provide the serial number of the wheelchair dropped off on 5/26/24. Facility claims that Apria never dropped off any wheelchair, to the best of their knowledge. Apria retrieved a wheelchair from facility as of 11/19/24. However, per the Apria local branch customer service representative, the wheelchair returned may not be the property of Apria as no serial number is present. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20241114141725
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: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2025
Section Cited
CCR
87507(f)
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87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met by licensee as evidenced by: Facility did not provide resident's authorized representative
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Facility to submit LIC9098 self-certifying they will, to the best of their ability, mitigate billing errors by reviewing all billing statements before issuing to residents and/or their responsible parties, by plan of correction due date.
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with the correct refund and facility billed resident's authorized representative after resident's departure from facility for incontinence items, which poses a 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: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5