Staffing, personnel, and training
Cited in 5 reports, with 6 deficiencies in total.
BROOKDALE CHANATE
3250 CHANATE RD, Santa Rosa CA 95404
140 bedsLatest official report Aug 11, 2026Licensed
Additional info
- Telephone
- (707) 575-7503
- Licensee
- BKD ARBORS OF SANTA ROSA LLC
- Administrator
- PATRICIA GUSTIN
- Contact
- PATRICIA GUSTIN
- License first date
- Mar 26, 2010
- License effective date
- Mar 26, 2010
- District office
- SANTA ROSA RO · (707) 588-5026
- Regional office
- 21
- Clients served
- 983 - RCFE / DEMENTIA
Summary
The available records show 22 Type A and 18 Type B deficiencies for this facility.
- Most recent inspection
- Jun 16, 2026
- Most recent deficiency
- Aug 11, 2026
No later report is available, so the records do not show what happened afterward.
What Type A and Type B mean
- Type A
- 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
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 18 Sonoma County facilities licensed for 50 or more beds, except where too few exist to state one — those come from facilities with 7 or more beds.
In the available public five-year record, CCLD published 44 reports for this facility: 24 inspections, 20 complaint investigations, and 0 licensing or administrative records.
Those records contain 22 Type A and 18 Type B deficiencies.
7 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 24
- Recorded deficiencies
- 40
- Type A deficiencies
- 22
- Type B deficiencies
- 18
- Substantiated complaints
- 14
- Repeated topics
- 8
More than the typical 9
5 in the last 12 months
Well above the typical 9
3 in the last 12 months
Well above the typical 4
1 in the last 12 months
Well above the typical 5
2 in the last 12 months
Well above the typical 2
1 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Medical and dental care
Cited in 5 reports, with 5 deficiencies in total.
Facility condition and maintenance
Cited in 4 reports, with 5 deficiencies in total.
Background checks
Cited in 2 reports, with 3 deficiencies in total.
Health conditions and treatments
Cited in 2 reports, with 3 deficiencies in total.
Administrator qualifications
Cited in 2 reports, with 2 deficiencies in total.
Incident reporting
Cited in 2 reports, with 2 deficiencies in total.
Resident rights
Cited in 2 reports, with 2 deficiencies in total.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType A
- Official classification
- Type A
- Official code
- 1569.269(A)(6)
- Regulation authority
- HSC
What the official deficiency says
§1569.269 Enumerated rights (a) Residents of RCFE shall have all of the following rights: (6) To care, supervision & services that meet their individual needs & are delivered by staff that are sufficient in numbers... & competency to meet their needs. This requirement has not been met as evidence by: Based on LPA’s records review of alarm response report, staff schedules for the month of June 2025 & interviews conducted with staff & residents in care, the facility did not ensure that staff on duty was sufficient to respond in a timely manner to assist residents in care which poses an immediate risk to the health & safety of residents in care.
Official plan of correction
Administrator agrees to submit a plan to ensure staffing is adequate to meet residents’ needs timely. Written plan will be submitted to CCL by POC due date. The Department will be scheduling a meeting to discuss areas of concern and non-compliance.
Deadline recorded: Aug 12, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 12, 2026
Correction not verified in available records
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations2 substantiated · 1 unsubstantiated · 0 unfounded · 2 cited
Resident rightsType B
- Official classification
- Type B
- Official code
- 1569.269
- Regulation authority
- HSC
What the official deficiency says
§1569.269 Enumerated rights... a)Residents...shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs...delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by licensee as evidenced by: Based on LPA record review of facility's pendant call button system log, the licensee did not comply with the section cited above in that between 2/9/25 and 2/13/25 residents pushed their pendant call button at least 192 times. Of those 192 times at least 42 never got a response, which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
Facility to ensure that pendant call button system is in good repair and operational, staff is sufficient to answer calls in a timely manner, when residents are in need of assistance. Facility to submit three day pendant call button system log to CCL showing all calls answered within a timely manner by plan of correction due date. Admin agrees that within 10-12 minutes can be defined as within a timely manner.
Deadline recorded: Mar 12, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 12, 2025
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87625(b)(3)
- Regulation authority
- CCR
What the official deficiency says
87625 Managed Incontinence (b) In addition to Section 87611... 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 was not met by licensee as evidenced by: Based on LPA interviews of facility's pendant call button system log, the licensee did not comply with the section cited above in that two [2] out of [2] residents that require staff assistance to manage and change their briefs waited long periods of time before staff arrived to change them, on least two occasions they waited over an hour, hich poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
Facility to conduct resident rights training for all care staff providing direct care to residents. Training to be at least one hour in duration and completed no later than 3/26/25.
Deadline recorded: Mar 26, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 26, 2025
Correction not verified in available records
Complaint
Allegations2 substantiated · 1 unsubstantiated · 0 unfounded · 1 cited
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87507(f)
- Regulation authority
- CCR
What the official deficiency says
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 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.
Official plan of correction
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.
Deadline recorded: Jan 16, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jan 16, 2025
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met by licensee as evidenced by: Based on LPA record review, R1 received the incorrect dosing of Sevelamer from 11/27/24 through 12/16/24, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
Facility has discontinued incorrect prescription dose for R1 and implemented dosing that matches physician's orders for R1. Facility to submit plan to conduct training for all Med Techs on ensuring the reisdent's current medications on eMAR match respective residents' physician's orders by plan of correction due date. Proof of training to be submitted to CCL no later than 1/3/25
Deadline recorded: Dec 30, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Dec 30, 2024
Correction not verified in available records
Complaint
Allegations1 substantiated · 2 unsubstantiated · 0 unfounded · 1 cited · investigated over 2 visits
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations2 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411(a)
- Regulation authority
- CCR
What the official deficiency says
87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: based on record review, the Licensee did not comply with the section cited above. Multiple call records showed that residents waited for at least 30 minutes or longer to receive assistance from care staff or did not receive assistance at all. This poses an immediate health, safety or personal rights risk to residents in care.
Official plan of correction
Licensee to submit a written plan outlining how resident care needs will be met when all or part of the facility's signal system is inoperable. Plan to be submitted by POC due date, 01/09/2024.
Deadline recorded: Jan 9, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jan 9, 2024
Correction not verified in available records
Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87303(i)
- Regulation authority
- CCR
What the official deficiency says
87303 Maintenance & Operation (i) Facilities shall have signal systems...:(1)All facilities licensed for 16 or more...(A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce... signal...loud enough to summon staff. This requirement was not met as evidenced by: based record review and interviews conducted, Licensee did not comply with section cited above. Facility call cords need replacement and pagers don't always indicate resident calls. This poses an immediate health, safety or personal rights risk to residents in care.
Official plan of correction
Licensee to submit a written plan/protocol on how facility will ensure that their signal system equipment remains operable. Facility to also outline how resident care will be maintained and responded to timely by care staff. Plan/protocol to be submitted by POC due date of 01/09/2024. Licensee to conduct In-service training on facility plan/policy with all care staff. In-service Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures by POC due date of 01/18/2024.
Deadline recorded: Jan 9, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jan 9, 2024
Correction not verified in available records
Complaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411(a)
- Regulation authority
- CCR
What the official deficiency says
87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Licensee did not meet this requirement based on document review confirming that the call bells for multiple residents was not responded to by staff. This is an immediate risk to the health and safety of residents in care.
Official plan of correction
Based on conversation with facility management, facility has provided and plans to provide additional training to staff regarding responding to the needs of residents. Deficiency is cleared.
Deadline recorded: Dec 1, 2023. A deadline is not proof that correction was completed.
Official record says corrected or clearedOn or before Nov 30, 2023
Correction deadline recordedDeadline Dec 1, 2023
Complaint
Allegations2 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411(a)
- Regulation authority
- CCR
What the official deficiency says
87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports...This requirement was not been met as evidenced by interviews and record review showing that caregivers have worked by themselves despite residents requireing two-person assists. This is an immediate risk.
Official plan of correction
Facility agrees to submit a written plan indicating how they will ensure sufficient staffing at all times to meet the needs of residents who require a two-person assist no later than 11/21/2023.
Deadline recorded: Nov 21, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 21, 2023
Correction not verified in available records
Basic services and supervisionType B
- Official classification
- Type B
- Official code
- 87464(d)
- Regulation authority
- CCR
What the official deficiency says
87464 Basic Services A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by interviews revelaing that there is not always incontinence supplies resulting in staff using supplies from other residents.
Official plan of correction
Facility agrees to provide training to staff regarding facility protocol to obtain incontinence supplies and submit proof of training to CCL no later than 11/30/2023.
Deadline recorded: Nov 30, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 30, 2023
Correction not verified in available records
Complaint
Part of the complaint whose outcome is recorded on Jul 11, 2024 · Control 21-AS-20230921102025
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(a)(1)(A)
- Regulation authority
- CCR
What the official deficiency says
87211 Reporting Requirement (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following: (1) A written report shall be submitted to the licensing agency & to person responsible for the resident within 7 days of the occurrence of any of the events specified in (A) through (D) below...(A) Death of any resident from any cause regardless of where the death occurred... Licensee didn't meet requirement as evidenced by: Based on interviews & document review death report was not provided to responsible person.
Official plan of correction
Facility to submit self-certification that they have provided the death report to R1's responsible party/representative no later than 11/10/2023
Deadline recorded: Nov 10, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 10, 2023
Correction not verified in available records
Complaint
Allegations2 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411
- Regulation authority
- CCR
What the official deficiency says
87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Licensee did not meet this requirement based on interviews that confirm not all resident's needs were met timely due to the signal system being down and staff not being able to supervise per stated protocol. This is an immediate risk to the health and safety of residents in care.
Official plan of correction
Administrator to provide CCL the written facility policy and/or protocol regarding how resident's needs are met when all or part of the signal system is inoperable and how resident's needs are met during those times by POC due date, 10/24/2023.
Deadline recorded: Oct 24, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 24, 2023
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(i)
- Regulation authority
- CCR
What the official deficiency says
87303 Maintenance & Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. Requirement not met based on interviews indicating signal system was inoperable for multiple weeks.
Official plan of correction
Signal system has been repaired. Deficiency is cleared.
Deadline recorded: Oct 24, 2023. A deadline is not proof that correction was completed.
Official record says corrected or clearedOn or before Oct 23, 2023
Correction deadline recordedDeadline Oct 24, 2023
Complaint
Allegations0 substantiated · 5 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.1(a)(1)
- Regulation authority
- CCR
What the official deficiency says
87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met based on interviews showing that S1 raised their voice at a resident. This is an immediate risk to personal rights.
Official plan of correction
Facility has addressed the situation and further correction is not needed. Deficiency is cleared.
Deadline recorded: Oct 20, 2022. A deadline is not proof that correction was completed.
Official record says corrected or clearedOn or before Oct 19, 2022
Correction deadline recordedDeadline Oct 20, 2022
Complaint
Allegations1 substantiated · 4 unsubstantiated · 0 unfounded · 1 cited
Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87303(i)(1)
- Regulation authority
- CCR
What the official deficiency says
Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit Requirement has not been met based on review of review of call logs for resident over a f15 day period showing that out of 125 calls, 42 of them were responded to 15 minutes or later and 6 were not responded to. This is am immediate risk to health and safety.
Official plan of correction
Per discussion with Administrator, they will be adding a Quality Assurance componennt to ensure compliance and will submit more a detailed plan to CCL in writing to CCL by POC due date, 10/20/2022.
Deadline recorded: Oct 20, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 20, 2022
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Dementia careType A
- Official classification
- Type A
- Official code
- 87705(j)
- Regulation authority
- CCR
What the official deficiency says
87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement has not been met as evidenced by interview and document review showing that resident eloped the facility despite not being able to be in the community by themselves. This is an immediate risk to the health and safety nof residents in care.
Official plan of correction
Administrator agrees to submit the updated elopement protocol, which they have updated due to this incident to CCL by POC due date, 7/28/2022. An immediate civil penalty in the amount of $500.00 is issued today for the violation of a regulation resulting in bodily injury or illness of a person in care.
Deadline recorded: Jul 28, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jul 28, 2022
Correction not verified in available records
Complaint
Allegations3 substantiated · 1 unsubstantiated · 0 unfounded · 3 cited
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87625(b)(3)
- Regulation authority
- CCR
What the official deficiency says
87625 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 has not been met as evidenced by interview and observation showing that a resident was left in a soiled brief until after eating and resident's room smelled of urine. This is an immediate risk to the health and safety nof residents in care.
Official plan of correction
Licensee agrees to submit planned date of a staff in-service regarding regulation 87625 by POC due date, 5/27/2022. In-service to be completed no later than 6/10/2022.
Deadline recorded: May 27, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline May 27, 2022
Correction not verified in available records
Basic services and supervisionType A
- Official classification
- Type A
- Official code
- 87466
- Regulation authority
- CCR
What the official deficiency says
87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional & social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains... are observed, the licensee shall ensure that such changes are documented & brought to the attention of the resident's physician & the resident's responsible person, if any. Requirement hasn't been met as evidenced by facility not notifying doctor of weight loss. This is an immediate risk to the health and safety nof residents in care.
Official plan of correction
Licensee agrees to submit planned date of a staff in-service regarding regulation 87466 by POC due date, 5/27/2022. In-service to be completed no later than 6/10/2022.
Deadline recorded: May 27, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline May 27, 2022
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.2(a)(1)
- Regulation authority
- CCR
What the official deficiency says
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations... This requirement has not been met as evidenced by interviews confirming that a resident in memory care goes into other resident's rooms and goes through their personal items. This is a potential risk to the personal rights of residents in care.
Official plan of correction
Adminsitrator agrees to submit a written plan indicating what they will do to ensure that residents do not go into other resident's rooms uninvited and/or go through other resident's personal property of resident by POC due date, 6/3/2022.
Deadline recorded: Jun 3, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jun 3, 2022
Correction not verified in available records
Complaint
Allegations0 substantiated · 3 unsubstantiated · 0 unfounded
No deficiencies recorded in this report1 complaint has no published investigation report
The official record holds these complaints, but no investigation report was published for them. Their outcome is shown as the source recorded it.
- Jul 23, 2025 · Control 21-AS-20250602090022
Allegations3 substantiated · 0 unsubstantiated · 0 unfounded · 3 cited
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology