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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601255
Report Date: 06/13/2024
Date Signed: 06/13/2024 01:06:04 PM

Unsubstantiated


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
06/10/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240610114221
FACILITY NAME:BROOKDALE NORTH FREMONTFACILITY NUMBER:
015601255
ADMINISTRATOR:HALL, SIMONE SFACILITY TYPE:
740
ADDRESS:38035 MARTHA AVETELEPHONE:
(510) 797-4011
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:40CENSUS: 28DATE:
06/13/2024
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Simone Hall, Executive DirectorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Resident fell multiple times due to staff neglect resulting in injuries
INVESTIGATION FINDINGS:
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On 6/13/2024 at 10:20am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit and to deliver complaint findings for the allegation above. LPA met with Simone Hall, Executive Director and explained the reason for the visit.

During the investigation LPA interviewed staff , witness, obtained and reviewed staff schedule, client roster, physician's report, appraisal needs and services plan, admission agreement, hospice notes, and progress notes for R1. Based on interviews and documentation R1's falls is not due to staff neglect there has been a decline in R1's health. S1 stated there will be a meeting with R1's responsible party to discuss

Continued on LIC9099.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
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 2
Control Number 15-AS-20240610114221
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: 06/13/2024
NARRATIVE
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Continued from LIC9099.

R1's change of condition. LPA reviewed progress notes from the facility and the hospice agency. Hospice notes dated 5/12/2024 stated there would be a follow-up visitor for R1's fall which occurred on 5/11/2024. Progress notes dated 5/30/2024 indicated there was a conversation with R1's responsible party about increased needs.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2