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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601255
Report Date: 01/25/2021
Date Signed: 01/25/2021 03:08:20 PM



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
01/20/2021 and conducted by Evaluator Allison O'Hollaren
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210120111529
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: 29DATE:
01/25/2021
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Ivette ColondresTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility does not follow regulation on medical assessment.
INVESTIGATION FINDINGS:
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On 01/25/2021 at 2:55pm, LPA Allison O'Hollaren conducted an unannounced continuing complaint visit meeting with Administrator, Ivette Colondres, for the purpose of delivering the finding for this complaint. Due to the State’s current shelter-in-place order the visit was conducted via telephone.

Based on interviews conducted and records reviewed, it was found that the RP completed and submitted a standard CCLD Physician’s Report form, which contained the necessary information and was accepted by the facility.

Continued...

Unfounded
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: 01/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021
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-20210120111529
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: 01/25/2021
NARRATIVE
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The Department has investigated the complaint and has found the allegation to be Unfounded, meaning the allegation was false, could not have happened and/or is without reasonable basis.

Exit interview conducted and a copy of this report was provided by mail.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2