496803241-9-9-2025-21-AS-MCUA-DLCPMA-20250909112601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803241
Report Date: 09/09/2025
Date Signed: 09/09/2025 11:26:09 AM

Document Has Been Signed on 09/09/2025 11:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	BROOKDALE CHANATE		FACILITY NUMBER:	496803241
ADMINISTRATOR/ DIRECTOR:	PATRICIA GUSTIN		FACILITY TYPE:	740
ADDRESS:	3250 CHANATE RD		TELEPHONE:	(707) 575-7503
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY: 140		CENSUS: 102	DATE:	09/09/2025
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Patricia Gustin (Administrator)		TIME VISIT/ INSPECTION COMPLETED:	11:49 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management visit to follow up on five self-incident report and one death report dated between 8/25/25 & 9/5/25 received by the department regarding falls in assisted living unit and met with Patricia Gustin, Administrator. Death report received on 8/27/25 indicates that on 8/25/25 the facility was notified by an outside party that resident (R1) passed away on 8/25/25 while in the hospital. Previously, on 8/12/25 the department received a self-incident report notifying CCL about R1's hospitalization on 8/7/25 due to altered mental status and weakness. During today's visit, LPA requested death certificate because R1 was not receiving hospice services at the time of their passing. According to death report, R1 had a diagnosis of cirrhosis of the liver, kidney failure and hypertensive heart disease. -On 8/29/25, incident received dated 8/20/25 resident (R2) called for assistance due to a fall after returning from the hospital, staff called 911 to transport R2 back to the hospital for increased falls and change of condition, responsible parties were notified. Today, LPA learned that R2 was transferred to a rehabilitation facility for treatment and there is no date for them to return to the facility. -On 8/29/25, incident dated 8/27/25 reported that resident (R3) was observed by med-technician while passing their medications that R3 was lying on the floor in a prone position with their walker positioned on their back. Continues on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROOKDALE CHANATE	FACILITY NUMBER: 496803241
	VISIT DATE: 09/09/2025

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Continued from LIC809...
R3 could not tell staff how the incident occurred, no injuries were noted, but staff determined to call 911 to transport R3 for further evaluation, responsible parties were notified. During today's visit, LPA reviewed R3's records including care plan updated on 8/30/25 that reflects the change of condition alerting staff of heightened risk for falling.

-On 8/29/25, third incident report dated 8/27/25 indicates that resident (R4) pressed their call alert pendant at about 1:15pm, upon staff arrival, family member was present in their room and told staff that R4 had fallen while arising from off the toilet and reported that R4 struck their head, staff assessed R4, but there were no visible injuries noted and R4 denied any acute pain nor discomfort, and staff followed the facility protocol to call 911 to transport R4 to the hospital for further evaluation. R4 was diagnosed with a closed heads injury and no new orders were issued. R4 was placed on increased round checks to be monitored for any further effects from the fall. On 9/5/25 another incident report was submitted to CCL notifying that on 9/1/25 at approximate 3pm, staff entered R4's apartment and noticed that R4's recliner had tipped over, R4 was seated on the floor next to the chair, and they were unable to recall what happened, R4 appeared confused, staff assessed them and called 911. Emergency team determined that R4 had a very slow and irregular heartbeat and they transport them to the emergency room for further assessment. Responsible parties were notified. R4 returned to the community same day and have been placed on alerting chart. Today, LPA was provided with updated care plan dated 8/27/25 including increased assistance needed in the bathroom to reduce fall risk considering a review of current medications with their physician to reduce the possibility of side effects.
The last incident report received on 9/2/25 it was dated 8/30/25 indicating that resident (R5) was noticed by staff wandering in the hallways which was unusual for the resident. R5 could not remember when was the last time that they ate nor even if they had a recent bowel movement. Staff assessed the resident and did not observe any signs of injury, but they called 911 and resident was taken to the emergency room for further evaluation. Responsible parties were notified. LPA was informed that the facility is currently in the process of obtaining updated physician to update their care plan.
No citations were issued during today's visit. Exit interview conducted with Administrator and copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/09/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025

LIC809 (FAS) - (06/04)

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