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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601255
Report Date: 12/08/2020
Date Signed: 12/08/2020 10:54:07 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2020 and conducted by Evaluator Allison O'Hollaren
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20201019162017
FACILITY NAME:BROOKDALE NORTH FREMONTFACILITY NUMBER:
015601255
ADMINISTRATOR:IVETTE COLONDRESFACILITY TYPE:
740
ADDRESS:38035 MARTHA AVETELEPHONE:
(510) 797-4011
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:40CENSUS: 30DATE:
12/08/2020
UNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Ivette ColondresTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Resident wandered from the facility.
INVESTIGATION FINDINGS:
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On 12/08/2020 at 8:48am Licensing Program Analyst Allison O'Hollaren conducted a continuing complaint visit meeting with S4. Due to the State's current COVID-19 shelter in place order the visit was conducted by telephone.

During investigation it was confirmed that subject resident (R1) had on 10/13/2020 left the facility unassisted and was found by staff across from the facility. LPA observed in R1's file that the resident cannot leave unassisted. The facility did report the incident to CCLD.

The Department has conducted an investigation into the above allegation and based upon observations, records review, and interviews conducted, the preponderance of
Continued on 809C.....

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20201019162017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BROOKDALE NORTH FREMONT
FACILITY NUMBER: 015601255
VISIT DATE: 12/08/2020
NARRATIVE
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evidence standard has been met, therefore the above allegation was found to be SUBSTANTIATED.

The deficiency is cited per CCR title 22. Failure to provide proof of correction by POC date may result in civil penalties. Exit interview conducted and appeal right provided. Due to the State's current Shelter in Place Order a copy of this report was provided by email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20201019162017
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE NORTH FREMONT
FACILITY NUMBER: 015601255
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2020
Section Cited
HSC
1569.312(e)
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Every facility required to be licensed under this chapter shall provide at least the following basic services: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their...
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By POC date, facility will submit to CCLD a plan preventing residents who cannot leave unassisted from exiting the facility.
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general health, safety, and well-being. This requirement was not met as evidenced by: LPA AO determined that R1 had left the facility unassisted which is an immediate threat to the health and safety of residents in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3