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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803241
Report Date: 02/19/2025
Date Signed: 02/19/2025 05:10:19 PM

Document Has Been Signed on 02/19/2025 05:10 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:		ALVARADO, ROBERTFACILITY TYPE:
740
ADDRESS:3250 CHANATE RDTELEPHONE:
(707) 575-7503
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 140CENSUS: DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
05:24 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Christi Coppo and Ali Deniz arrived unannounced to conduct a required Annual inspection and was greeted by receptionist. Administrator Robert Alvarado arrived later. Facility contact information was reviewed.

At approximately 9:45am LPAs toured the building and grounds. LPAs toured main kitchen and found it to be clean and organized. LPAs observed speed rack of sandwiches and salads that were not covered with plastic. LPAs and Director of Food Services (DFS) discussed getting a cover/tarp for the speed rack. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner but many open items not covered with tight fitting lid, such as ice cream and veggie burger patties. LPAs and DFS discussed ensuring all items that are open or pre-made must be wrapped or covered with a lid. LPAs toured emergency food and water supply room, facility has supply within regulation. LPAs measured temperature of water in main kitchen to be 148 degrees F but did not have a caution hot water sign above sink; however, a caution sign was observed on ancillary sink in kitchen. LPAs and DFS discussed putting a caution sign above main sink. LPAs measured temperature of water in kitchen by Activity Director's office to be 109 degrees F, which is within the allowable range of 105 to 120 degrees F

Fire extinguishers were last inspected both on 2/12/24 and 4/10/24. Fire extinguishers last inspected 2/12/24 were charged and arrow showing in the green. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired and serviced by a vendor. Director of Maintenance (DOM) explained to LPAs that a vendor came to the facility that DOM thought was the vendor that served the fire panel but DOM was mistaken and company tampered with fire panel box such that it was rendered to not working properly. Vendor that actually does service came on 2/11/25 and the Automatic Sprinkler System failed inspection. Deficiencies found were listed as: riser pressure gauges are over 5 years old and need to be replaced, four

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 25
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
VISIT DATE: 02/19/2025
NARRATIVE
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Continued from 809...

in total; the water flow switch for the 1st and 2nd floor sprinklers didn't activate into alarm when tested. A purchase order was placed for the risers and another 5 year inspection will be conducted with a date yet to be determined (deficiency cited, see 809D). Facility’s last quarterly disaster drill was conducted 1/29/25. Facility has a backup generator for use during a power outage.

LPAs toured Memory Care unit and found the unit to be at a comfortable temperature with residents engaged in activity or watching T.V. LPAs measured temperature of water in Memory Care kitchen to be 110.4 degrees F which is within the allowable range of 105 to 120 degrees F. LPAs observed trash, food scraps and pieces of discarded food items, cup with black substance and white substance, and used paper towels to be discarded and piled up underneath sink (deficiency cited, see 809D). LPA observed notable urine smell coming from room next Sauna room in Memory Care (deficiency cited, see 809D).

At approximately 11:00am LPAs conducted review of 7 staff records. Staff (S1, S2, S3, and S4) did not have the total required hours of training completed (deficiency cited, see 809D).

Seven staff (S5, S6, S7, S8, S9, S10, and S11) were listed on staff roster but did not have fingerprint clearance (deficiency cited, see 809D and civil penalty assessed). LPA, Admin, and Business Operations Manager Danielle Oseguera (BOM) discussed those staff not having fingerprint clearance. BOM concerned as she remembers waiting for the clearance before putting them on the floor; however per Gaurdian S5-S11 do not have any applications and do not have clearance. Additionally two [2] staff listed on staff roster were not associated to the facility. LPA and Admin discussed staff not present on Guardian roster that were listed as current staff on facility roster. Admin advised that for some reason these employees are listed as separated in Guardian but are not actually separated. Admin and BOM showed LPA on Guardian site the separation dates of this staff. Admin agrees to go back in and re-associate each one.

At approximately 12:00pm LPAs conducted a review of 7 resident records. All documentation present.

Continued on 809C(2)...

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

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
Page: 15 of 25
Document Has Been Signed on 03/05/2025 03:42 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/03/2025 01:12 PM


Created By: Christi Coppo On 02/19/2025 at 11:45 AM
Link to Parent Document Below:
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: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87405(a)
87405(a) Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Administrator does not have an actively current Administrator certificate. This poses an immediate health, safety or personal rights risk to residents
Deficient Practice Statement
1
2
3
4
Based on LPAs record review, the licensee did not comply with the section cited above in that Administrator's certificate was in renewal status but was subsequently removed from pending status due to not having enough training hours completed and required forms not submitted, which poses an immediate health, safety or personal rights risk to persons in care. **amended to include deficient practice statement language and plan of correction language due to computer printing error.**
POC Due Date: 03/06/2025
Plan of Correction
1
2
3
4
Facility to submit plan of to complete the required remaining training hours needed and submit the forms necessary to obtain certificate renewal by plan of correction date of 3/6/25. *amended to correct plan of correction due date due to computer printing error*
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
Page: 16 of 25
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
VISIT DATE: 02/19/2025
NARRATIVE
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Continued from 809C...

At approximately 3:00pm LPAs and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies


At approximately 4:15pm LPA walked facility grounds. No obstructions found. Evacuation chair present in stairwell.

Robert Alvarado Administrator Certificate 7017266740 is currently expired. LPA called Administrator Certification Bureau and was told by the representative that the certificate was in renewal status but was subsequently removed from pending status due to not having enough training hours completed and required forms not submitted (deficiency cited, see 809D).



Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

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

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

***Due to computer problems citations and civil penalties not printing. LPA obtained signatures for 809 and 809C pages and will return at a later date to complete issuing of citations and civil penalties as part of annual inspection.***

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

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
Page: 17 of 25
Document Has Been Signed on 03/05/2025 03:43 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/03/2025 01:16 PM


Created By: Christi Coppo On 02/19/2025 at 04:35 PM
Link to Parent Document Below:
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: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that Automatic Sprinkler System failed inspection per vendor inspection report and the Emergency exit door at the end of the AL hallway (NW exit hall #2) was propped open with a brick, which poses an immediate health, safety or personal rights risk to persons in care. *amended to include deficient practice statement language and plan of correction language due to computer printing error.**
POC Due Date: 03/14/2025
Plan of Correction
1
2
3
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Facility to submit vendor inspection report indicating Automatic Sprinkler System has passed inspection by plan of correciton due date. During visit on 2/19/25, LPA observed brick propping open exit door was removed and exit door closed, this portion of the deficiency is cleared. *amended to add POC language due to computer printing error*
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S5, S6, S7, S8, S9, S10, and S11 did not have fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care. *amended to include deficient practice statement language and plan of correction language due to computer printing error.* ***civil penalties assessed***
POC Due Date: 03/06/2025
Plan of Correction
1
2
3
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Facility to submit LIC9098 self-certifying that S5, S6, S7, S8, S9, S10, and S11 will not work or be present at the facility until fingerprint clearance is obtained and dcoumentation of fingerprint clearance is presnet in each staff's respective staff file. *amended to add POC language due to computer printing error* **civil penalties assessed**
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
Page: 18 of 25
Document Has Been Signed on 03/05/2025 03:44 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/03/2025 01:24 PM


Created By: Christi Coppo On 02/19/2025 at 04:35 PM
Link to Parent Document Below:
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: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance 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:
Deficient Practice Statement
1
2
3
4
Based on LPAs and Admin observation, the licensee did not comply with the section cited above in that LPAs observed trash, food scraps and pieces of discarded food items, cup with black substance and white substance, and used paper towels to be discarded and piled up underneath sink in Memory Care kitchen, which poses a potential health, safety or personal rights risk to persons in care.**amended to include deficient practice statement language and plan of correction language due to computer printing error.**
POC Due Date: 03/07/2025
Plan of Correction
1
2
3
4
Facility to submit pictures of cleaned Memory Care kitchen sink area including underneath the sink by plan of correction due date. *amended to add POC language due to computer printing error* LPA observed on cleaned sink on 3/5/25. Deficiency cleared.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs and Admin observation and record review, the licensee did not comply with the section cited above in that S1, S2, S3, and S4 did not have the required number of training hours completed, which poses a potential health, safety or personal rights risk to persons in care. **amended to include deficient practice statement language and plan of correction language due to computer printing error.**
POC Due Date: 03/21/2025
Plan of Correction
1
2
3
4
Facility to submit current completed training hours for S1, S2, S3, and S4 in the amount of hours required per regulation based on thier respective lengths of employment by plan of correciton due date. *amended to add POC language due to computer printing error*
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
Page: 19 of 25
Document Has Been Signed on 03/05/2025 03:47 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/03/2025 02:17 PM


Created By: Christi Coppo On 02/19/2025 at 04:35 PM
Link to Parent Document Below:
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: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs observation, the licensee did not comply with the section cited above in that LPA observed notable urine smell coming from room next Sauna room in Memory Care, which poses a potential health, safety or personal rights risk to persons in care. **amended to include deficient practice statement language and plan of correction language due to computer printing error.**
POC Due Date: 03/07/2025
Plan of Correction
1
2
3
4
Facility to submit LIC9098 self-certifying they have cleaned and addressed the incontinence odor issue from the Memory Care Unit and that they further self-certify that the facility will remain free of incontinence odors at all times. *amended to correct plan of correction due date due to computer printing error*
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
Page: 20 of 25
Document Has Been Signed on 02/19/2025 05:10 PM - It Cannot Be Edited


Created By: Christi Coppo On 02/19/2025 at 04:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BROOKDALE CHANATE
FACILITY NUMBER: 496803241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
Page: 22 of 25
Document Has Been Signed on 02/19/2025 05:10 PM - It Cannot Be Edited


Created By: Christi Coppo On 02/19/2025 at 04:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BROOKDALE CHANATE
FACILITY NUMBER: 496803241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance 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:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
Page: 23 of 25
Document Has Been Signed on 02/19/2025 05:10 PM - It Cannot Be Edited


Created By: Christi Coppo On 02/19/2025 at 04:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BROOKDALE CHANATE
FACILITY NUMBER: 496803241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
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