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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803241
Report Date: 01/23/2026
Date Signed: 01/23/2026 03:31:16 PM

Document Has Been Signed on 01/23/2026 03:31 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BROOKDALE CHANATEFACILITY NUMBER:
496803241
ADMINISTRATOR/
DIRECTOR:		PATRICIA GUSTINFACILITY TYPE:
740
ADDRESS:3250 CHANATE RDTELEPHONE:
(707) 575-7503
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 140CENSUS: 98DATE:
01/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:49 AM
MET WITH:Patricia Gustin (Administrator)TIME VISIT/
INSPECTION COMPLETED:
03:53 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Required 1 Year visit and met with Executive Director (ED)/Administrator, Patricia Gustin. Required postings observed. There are eight residents receiving hospice care services within the approved hospice waiver.

Facility has an approved dementia care plan. LPA obtained staff schedules for the Assisted Living and Memory Care Units for the month of January 2026 with a census of 98 residents in care indicates that the facility had an average of two caregivers on duty for residents in care and one medication technician (med-tech). Currently, there are currently 76 residents in Assisted Living area and 22 residents in Memory Care Unit. LPA/ED observed three caregivers present in memory care, one resident care coordinator and one med-tech. There are two caregivers present in assisted living area and one med-tech, there is one caregiver present who alternates between assisted living and memory care unit to assist with showers and incontinence care. LPA/ED toured the facility which included an inspection of assisted living and memory care, all common areas, hallways, and bathrooms observed had sufficient lighting. Residents rooms are furnished per regulation. Facility's Memory Care is allocated to one floor. The facility was a comfortable temperature. Passageways were free of obstructions. Cleaning products are in locked closets or on supervised and/or locked carts. Facility has a sufficient supply of cleaners, hygiene items and paper products. Multiple first aid kits were observed. A call button is located in each bathroom, LPA tested the call system in resident's rooms and staff response time was under three minutes. Continued on LIC 809-C..
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2026
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: 01/23/2026
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Continued from LIC809...

LPA/ED observed the memory care unit is on a delayed egress system, which it was approved in their fire clearance. The units two delayed egress doors were tested. There are evacuation chairs located at each stair. The elevators were last inspected on 7/16/25 and permit expires on 7/16/26. The facility has a generator in case of any power outages. The last fire drill was conducted 12/26/25. Fire extinguishers were observed to be last charged on February 2025. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected 3/26/25 & 10/3/25.

At approximately 10:25am, LPA/ED toured the kitchen area located in the second floor of the building. A tour and inspection of the kitchens and dining areas were found to be clean and sanitary except a cart containing dirty dishes had a bottle of disinfectant cleaner (technical advisory issued). Also, there were two prepared left over fruit cups and tray containing at least 38 pieces of food were observed uncover and not labeled. Per kitchen chef, the left over cups were going to be discarded and tray of food was ready to be fried, but the stove was not on. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. Refrigerators and freezers were at required temperatures. Menu includes a wide variety of foods from all of the food groups. A board in the kitchen has written instructions for residents with food allergies and restricted diets. Other cleaning products and medication carts that were observed on the floor were supervised and/or locked carts. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. During the tour, residents were observed participating in group activities in common areas. There are activities written on a board specified for both assisted living and memory care engagement. Water temperatures measured at between 107.3 and 112.1 degrees (F) which is within acceptable range of 105 to 120 degrees F. Bathrooms have non-skid surfaces and grab bars at the toilet and showers.

Additionally, LPA/ED noticed that garbage cans located in some resident's bathrooms do not have lids, LPA had a conversation with ED regarding the importance of providing garbage cans with well-fit covers (technical advisory issued). Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026
LIC809 (FAS) - (06/04)
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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: 01/23/2026
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Continued from LIC809C...

At approximately 11:14am, During the walk through of the six story building including assisted living and memory care, LPA/ED observed two resident's toilets were observed dirty, one located in the assisted living and one located in the memory care unit. Based on records review, the facility provided housekeeping schedule for the month of January 2026 for both areas, which indicates that room in assisted living area is scheduled to be cleaned two times per week (Sunday & Wednesday), unless that residents call to get assistance to clean their bathroom, the staff won't come to do so, which it was agreed and signed in their admission agreement. Regarding memory care area room, the housekeeping schedule revealed that the dirty toilet should have been cleaned today by 10am. According to ED, the housekeeping staff designated to memory care area called in sick this morning, and they were expecting another staff to come and cover for them.

- At 11:30 AM, LPA conducted a file review of six staff and ten residents. Residents receiving hospice services had a care plan that appears to be accurate to services being provided. All residents' care plans seems to have a person-centered approach and they are updated. Medical assessments are current and included a description of any known behavioral expression. One out of six (S1) staff did not have a current CPR/1st aid on file. According to ED, staff recently was hired as a housekeeper and they are in the process of training S1 as caregiver (Technical advisory was issued). All staff have required training hours complete. Patricia Gustin, administrator certificate 7010392740 expires on 6/8/2027. Medications and medication records were reviewed. Annual fees are current.

ED agrees to submit updated documents by 2/6/26: (LIC500) Personnel Report & Liability Insurance.



Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with ED/Administrator and copy of report was given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2026 03:31 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 01/23/2026 at 02:48 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: 01/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/ED observation, interview and record review, the licensee did not comply with the section cited above in two resident's toilets were observed dirty, one located in the assisted living and one located in the memory care unit. Based on records review, the facility housekeeping schedule revealed that the dirty toilet should have been cleaned today by 10am which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Administrator agrees to submnit a written plan how the facility will prevent this type of incidents from happening and they will submit written plan to CCL by POC due date to clear the citation.
Type B
Section Cited
CCR
87555(b)(9)

87555(b)(9) General Food Service Requirements. Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and interview with administrator the facility failed to label and or cover two prepared left over fruit cups and tray containing at least 38 pieces of food were observed uncover and not labeled which poses a potential health and safety risk to residents in care.

POC Due Date: 02/06/2026
Plan of Correction
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Administrator agrees to conduct a staff training pertaining to food storage and submit written plan how the facility will handle food storage of left overs by POC due date 2/6/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2026


LIC809 (FAS) - (06/04)
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