Inspection Reports for Brookdale Chanate

The visit was an unannounced case management visit to follow up on a suspected adult/elder financial abuse report submitted on 2025-09-24.

The suspected abuser was determined to be an outside party not involving the facility or its staff, and no deficiencies were observed or cited during the visit. Relevant parties including law enforcement and Ombudsman were cross reported.

The visit was complaint-related to suspected adult/elder financial abuse, but the complaint was not substantiated as it involved an outside party beyond the facility's jurisdiction.

Unannounced case management visit to follow up on five self-incident reports and one death report related to falls in the assisted living unit.

The visit reviewed multiple incidents involving resident falls and hospitalizations, including one resident death. Updated care plans and increased monitoring were noted, but no citations were issued during the visit.

The inspection was an unannounced case management visit to follow up on uncleared deficiencies cited during a complaint investigation on 2025-07-17.

The Administrator provided proof of correction for previously cited deficiencies related to resident needs follow-up and staffing schedules. Deficiencies cited on 2025-07-17 were cleared as of this visit.

Visit was a follow-up to complaint investigation #21-AS-20250602090022 dated 2025-07-17. Outstanding citations from that investigation were addressed during this visit.

An unannounced complaint investigation was conducted due to an allegation that staff were not keeping an accurate record of residents' payments.

The investigation found that a system glitch caused rejection of in-person check payments and automatic late fees, but the facility notified the resident to ignore these fees and provided consistent account records. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged staff were not keeping accurate records of resident payments, specifically citing late fees and billing discrepancies for resident R1. The allegation was found unsubstantiated after review and interviews.

The visit was an unannounced case management follow-up on a self-incident report regarding a medication error involving resident R1.

The facility failed to properly assist resident R1 with prescribed medication Namenda 5mg and 10mg, resulting in medication overdosing. The resident was monitored with no reported discomfort, and corrective actions including care plan updates and staff retraining were planned. A civil penalty was assessed for a repeat violation within 12 months.

The visit was triggered by a self-incident report dated 2025-04-07 regarding a medication error. The complaint was substantiated as the facility did not comply with medication assistance requirements, posing an immediate health and safety risk.

The inspection visit was conducted as a continuation of the Annual inspection originally conducted on 2025-02-19, to complete the annual compliance evaluation of the facility.

The annual inspection was completed with deficiencies cited from the California Code of Regulations and the Health and Safety Code. Appeal rights were given and discussed with the Administrator. Failure to correct deficiencies or repeat deficiencies within 12 months may result in civil penalties.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-01-27 regarding staff response times to pendant call system and care related to incontinence briefs.

The investigation substantiated that staff did not respond timely to pendant call system alerts, with 42 of 192 calls receiving no response and some residents waiting over 15 minutes. It was also substantiated that two residents requiring assistance with incontinence briefs experienced long wait times, sometimes over an hour. Another allegation of rough treatment was found unsubstantiated.

The complaint investigation was substantiated for allegations that staff did not respond timely to pendant call system alerts and left residents in soiled incontinence briefs for extended periods. The allegation of rough treatment was unsubstantiated.

The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing regulations and facility operations.

The inspection found multiple deficiencies including expired administrator certification, failure of the automatic sprinkler system inspection, uncovered food items, inadequate staff fingerprint clearances, incomplete staff training hours, unsanitary conditions in the Memory Care kitchen, and a notable urine odor in the Memory Care unit. Some deficiencies posed immediate health, safety, or personal rights risks to residents.

The visit was an unannounced case management inspection to amend a previous citation (9009D) issued on 12/27/2024 related to complaint 21-AS-20241217154914. The purpose was to address deficiencies regarding failure to submit an Incident Report related to a substantiated complaint allegation.

The inspection found that the facility failed to submit an Incident Report for a medication error involving resident R1, which posed a potential health, safety, or personal rights risk. A citation was issued for this deficiency, amending the previous citation to be cited under case management deficiencies (809D).

The visit was triggered by complaint 21-AS-20241217154914. The allegation was substantiated, but the facility failed to submit the required Incident Report to the licensing agency.

The visit was an unannounced Case Management - Incident inspection triggered by reported incidents including missing resident cash and a medication error involving administration of another resident's medications.

The facility reported two incidents: a resident missing $500-$600 in cash and a medication error where a resident was given another resident's medications, resulting in hospitalization. A deficiency was cited related to the medication error, requiring a plan of correction.

The visit was complaint-related due to incidents reported by the facility: missing resident cash and a medication error. The medication error was substantiated with a deficiency cited. The missing cash incident had no deficiencies cited.

Unannounced complaint investigation visit conducted due to complaints alleging the facility did not provide the correct refund to a resident's authorized representative, billed after resident's departure for incontinence items, and did not return a rented wheelchair.

Two allegations were substantiated: the facility did not provide the correct refund to the resident's authorized representative and billed incontinence items after the resident's departure. One allegation regarding failure to return a rented wheelchair was unsubstantiated due to lack of evidence.

The complaint investigation was substantiated for two allegations: incorrect refund to resident's authorized representative and erroneous billing for incontinence items after resident's departure. The allegation that the facility did not return a rented wheelchair was unsubstantiated due to insufficient evidence.

Unannounced complaint investigation visit conducted due to an allegation that the licensee failed to administer medications as prescribed by a physician.

The investigation substantiated that resident R1 received an incorrect dose of Sevelamer Carbonate from 11/27/24 through 12/16/24, which posed an immediate health and safety risk. The facility failed to report the medication error to Community Care Licensing and did not submit an incident report.

Complaint was substantiated. The allegation was that the licensee failed to administer medications as prescribed by the physician. The preponderance of evidence standard was met based on record review.

Licensing Program Analyst Christi Coppo arrived unannounced to open a complaint investigation at the facility due to concerns about the absence of a qualified and certified Administrator.

The facility did not have a qualified and currently certified Administrator present. The Interim Administrator lacked fingerprint clearance and an active Administrator certificate, posing an immediate health, safety, or personal rights risk to residents. Deficiencies were cited and a civil penalty was assessed.

Complaint investigation opened due to absence of a qualified Administrator. Interim Administrator lacks fingerprint clearance and active certification. Civil penalty assessed.

The visit was an unannounced case management inspection regarding an incident report received on 2024-08-09 about a resident elopement.

The investigation found that a resident with dementia eloped due to a north egress door not latching properly, causing the alarm not to sound. The resident was found safe and returned without injury. Staff training and an elopement drill were conducted following the incident.

The visit was complaint-related due to an incident report of resident elopement. The report details the investigation and corrective actions taken.

The inspection was an unannounced complaint investigation visit triggered by allegations that the facility did not notify the responsible party of a resident's change of condition and did not seek timely medical care for the resident.

The investigation included interviews and document reviews and found that the resident had been declining for about a year with low appetite and medication refusal due to pill size. On the day of passing, the resident became unresponsive and died at the facility. The complaint was determined to be unsubstantiated due to insufficient evidence to prove violations.

The complaint alleged failure to notify the responsible party of the resident's change of condition and failure to seek timely medical care. The complaint was found to be unsubstantiated based on record review and inconsistent statements during interviews.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not following a resident's needs and services plan, specifically regarding the care and rotation frequency of Resident 1.

The investigation included document reviews, interviews, and observations which revealed inconsistent statements about care provision. The Licensing Program Analyst was unable to determine if violations occurred due to conflicting information and evidence showing improvement in the resident's condition. The allegation was found to be unsubstantiated and no deficiencies were cited.

The complaint alleged that staff did not follow Resident 1's care plan by failing to change or rotate the resident every two hours as required. The investigation found inconsistent statements from staff and family, with some family members stating care was refused and others stating it was not. Hospice provider observations indicated care was provided and pressure injuries were improving. Ultimately, the complaint was unsubstantiated due to lack of preponderance of evidence.

The unannounced visit was conducted as a case management inspection pertaining to Incident Reports received by Community Care Licensing on 2/15/2024 and 2/20/2024.

The inspection found that the facility lacked a current certified Administrator, with a corporate representative temporarily filling the role but with an expired certificate in renewal status. Staff encountered combative and profane behavior from a resident's family member who was denying staff access to administer pain management medications, which were ultimately administered by hospice staff. Another incident involved a resident with suspected osteomyelitis whose care plan did not reflect the need for foot care, prompting a recommendation to update the care plan. No deficiencies were cited.

The visit was complaint-related based on incident reports involving resident care issues on 2/15/2024 and 2/20/2024. The complaint regarding denial of staff access to a resident for medication administration was investigated and addressed. The complaint about foot care needs for another resident was reviewed with recommendations for care plan updates. No substantiation status was explicitly stated.

The inspection was an unannounced annual continuation visit to evaluate compliance with regulations for an assisted living and memory care facility.

The facility was found to have well-organized staff files but had deficiencies including two staff members lacking current first aid certificates and one resident's routine medications not being properly documented or centrally stored as required.

Unannounced Required 1 Year visit to evaluate compliance with regulations for an assisted living and memory care facility.

The facility was found to be clean, well-maintained, and compliant with regulations including infection control, food supply, safety features, and documentation. No deficiencies were cited during the visit.

Unannounced complaint investigation visit conducted due to allegations that staff did not repair a resident's pull cord device and did not respond timely to resident alerts.

Investigation substantiated that some resident pull cords were inoperable and call system occasionally failed, resulting in residents waiting 30 minutes or longer for assistance or not receiving assistance at all. Immediate civil penalty of $500 was assessed for repeat violations.

Complaint was substantiated based on record review and staff interviews confirming that residents' pull cords were not repaired and call system failures caused delayed or absent responses to resident calls.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-10-23 regarding allegations that facility staff did not ensure that a resident's call button was accessible and that the facility was not meeting the needs of a resident in care.

The investigation found that the pull cord call button was accessible and laying on the resident's bed, and that the resident did not require one-to-one supervision as confirmed by the resident's doctor. The allegations were unsubstantiated and no deficiencies were cited during the inspection.

The complaint alleged that the resident's call button was not accessible because the pull cord was tucked behind the bed, and that the facility was not meeting the resident's needs by failing to provide constant supervision. The investigation found no evidence to substantiate these allegations.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that the facility failed to respond to a resident's pendant/call button/phone calls.

The investigation substantiated the allegation that staff failed to respond to residents' call pendants on multiple occasions, posing an immediate risk to resident health and safety. A civil penalty of $250 was assessed for repeated violations within a 12-month period.

The complaint was substantiated based on document review and evidence that staff failed to respond to residents' pendants/call buttons multiple times. A civil penalty was assessed for repeating regulation 87411(a) more than once in a 12 month period.

The inspection was an unannounced Case Management visit to follow up on two medication errors reported by the facility.

Two medication errors were identified: one resident was given a discontinued medication but did not suffer adverse effects, and another resident did not receive medication for approximately one week due to missing information in the medication database. Deficiencies were cited related to failure to assist residents with self-administered medications, posing an immediate risk to health and safety.

The visit was complaint-related, following up on two medication errors reported by the facility. No adverse effects were reported for either incident.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/27/2023 regarding insufficient staffing and lack of incontinence supplies for residents.

The investigation substantiated that the facility did not always have two caregivers available for residents requiring two-person transfers, and that incontinence supplies were not consistently available, leading to staff using supplies from other residents. Facility policies on supply procurement were not fully known by all staff.

The complaint was substantiated based on interviews and document reviews. Allegations included insufficient staffing for two-person resident transfers and inadequate provision of incontinence supplies. The facility was cited under California Code of Regulations sections 87411(a) and 87464(d).

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that the facility did not provide a written incident report to the responsible party.

The investigation substantiated that the facility failed to provide the resident's death report to the responsible party because the facility was unable to determine if the responsible party had authority to receive the report. The death report was not provided to the individual who signed the Admission Agreement, violating reporting requirements.

Complaint was substantiated. The allegation that the facility did not provide the resident's death report to the responsible party was confirmed based on interviews and record review.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-09-14 regarding non-functioning resident pendants and untimely staff assistance.

The investigation substantiated that the call bell system, including resident pendants, was inoperable for multiple weeks, resulting in staff not always meeting the required timelines to assist residents, which posed an immediate risk to resident health and safety.

The complaint was substantiated based on interviews and record reviews. Allegations included residents' pendants not working and staff not helping residents in a timely manner due to the call button system failure.

Unannounced complaint investigation conducted due to allegations that the facility did not meet resident's needs, did not follow resident's care plan, did not respond to call buttons, staff did not ensure resident received warm food, and did not properly respond to resident's injuries.

The investigation found conflicting information regarding the allegations, including issues with catheter bag emptying, meal delivery, call button response, and injury response. Despite the allegations, there was insufficient evidence to substantiate the claims, and no deficiencies were cited.

Complaint investigation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred. Allegations included failure to meet resident needs, failure to follow care plan, failure to respond to call buttons, failure to ensure warm food, and improper response to injuries.

The inspection was an unannounced Case Management visit following up on a recent incident where a resident was found on the floor and subsequently hospitalized, with notification of the resident's passing the next day.

No deficiencies were cited during this inspection. The Licensing Program Analyst reviewed documents and requested the facility obtain and provide a copy of the resident's death certificate to the Community Care Licensing division.

The inspection was an unannounced Case Management visit following up on a self-reported incident where a resident fell and was sent to the hospital, later passing away.

No deficiencies were cited during this inspection. The resident did not require 1:1 supervision, and the cause of death was not provided.

The inspection was an unannounced annual required inspection conducted by the Licensing Program Analyst to evaluate compliance with regulations.

The facility was found to be in compliance with no deficiencies cited. Observations included proper infection control measures, safe water temperatures, secured medications, up-to-date fire safety equipment, and staff certifications. The Administrator's certificate had expired but renewal paperwork was submitted and will be monitored.

The inspection was an unannounced Case Management visit to follow up on the passing of a resident who was not on hospice and to review a recent self-reported incident involving another resident and a family member.

No deficiencies were cited during this inspection. The Licensing Program Analyst reviewed medical documentation and incident reports as part of the follow-up.

The visit was complaint-related, following up on the passing of resident R1 and a self-reported incident involving resident R2 and a family member. Facility reported per Mandatory Reporting requirements.

The inspection was an unannounced Case Management visit to follow up on three residents who passed away but were not on hospice.

The inspection found no deficiencies. The report detailed the circumstances of three resident deaths, including hospital admissions and emergency response.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-07-26 alleging staff were not responding to call buttons, residents left soiled causing rash and UTI, failure to maintain hygiene, medication not administered as prescribed, and missing laundry.

The allegation that staff were not responding to call buttons was substantiated based on call log reviews showing delayed or no responses. The other allegations regarding resident hygiene, medication administration, and missing laundry were unsubstantiated due to insufficient evidence. No deficiencies were cited except for the call button response issue, which was cited as a Type A deficiency.

The complaint investigation was substantiated for the allegation that staff were not responding to call buttons timely, posing an immediate risk to resident health and safety. Other allegations including residents left soiled causing rash and UTI, failure to maintain hygiene, medication not administered as prescribed, and missing laundry were unsubstantiated.

An unannounced complaint investigation visit was conducted following a complaint received on 08/30/2022 alleging that staff did not treat a resident with dignity and respect.

The investigation substantiated the allegation that staff raised their voice at a resident, which was described as sharp, firm, and loud. The involved resident denied being fearful but confirmed staff yelled at them. The deficiency was cited under California Code of Regulations Title 22, Section 87468.1(a)(1) for failure to accord dignity to residents.

The complaint was substantiated based on evidence that staff communicated in a loud and demanding manner to a resident, violating the resident's dignity and respect.

The inspection was conducted as a Case Management - Incident visit following an incident report indicating that a staff member observed another staff treating a resident with a lack of dignity and respect.

During the unannounced visit, interviews were conducted with involved staff who denied recalling the events as described. The staff member involved no longer works at the facility. No deficiencies were cited during this inspection.

The visit was complaint-related based on an incident report alleging staff mistreatment of a resident. The involved staff denied the allegations and is no longer employed at the facility.

An unannounced complaint investigation was conducted due to an allegation of lack of supervision resulting in a resident eloping from the facility.

The investigation found that a resident who was unable to be in the community unassisted eloped the facility through a malfunctioning delayed egress door in the Memory Care unit. The resident was missing for approximately three hours before being found by local law enforcement and was diagnosed with a stress fracture. An immediate civil penalty of $500 was issued for the violation resulting in bodily injury.

The complaint was substantiated. The allegation was lack of supervision resulting in a resident eloping from the facility. The resident eloped through a malfunctioning delayed egress door and was found approximately 2.5 miles away with a stress fracture.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-03-01 regarding resident care needs not being met, facility cleanliness, safeguarding of resident property, and insufficient staffing.

The complaint investigation substantiated that resident care needs were not being met, the facility was not clean, and staff were not safeguarding resident property. The allegation of insufficient staffing was unsubstantiated. Deficiencies were cited related to managed incontinence, observation of residents, and personal rights violations.

The complaint investigation was substantiated for allegations that resident care needs were not met, the facility was not clean, and staff were not safeguarding resident property. The allegation of insufficient staffing was unsubstantiated.

An unannounced annual required inspection was conducted focusing on the Infection Control procedures and practices of the facility.

The facility had appropriate infection control signage, staff were observed wearing masks, and common areas were disinfected multiple times daily. Staff COVID-19 screenings were not documented for the day of inspection. Fire extinguishers were serviced but tags were not updated. No deficiencies were cited during this inspection.

Unannounced complaint investigation visit conducted in response to allegations that a staff member inappropriately handled a resident, left the resident on the floor after pulling her out of bed, and verbally threatened the resident.

The investigation found inconsistent information regarding the alleged incident, and based on police and physical exam reports showing no bruising or swelling, the complaint allegations were unsubstantiated and dismissed.

Complaint allegations included inappropriate handling of a resident, leaving the resident on the floor after pulling her out of bed, and verbal threats by staff. The complaint was found unsubstantiated due to lack of preponderance of evidence.

The inspection was conducted due to a report received from the facility where a resident accused a staff member of abuse. The facility reported the alleged abuse as required of mandated reporters.

The Licensing Program Analyst conducted interviews and reviewed documents related to the alleged abuse and found no deficiencies during this inspection.

The visit was complaint-related due to an allegation of staff abuse reported by a resident. The complaint was investigated and no deficiencies were cited.