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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601255
Report Date: 07/30/2021
Date Signed: 07/30/2021 10:39:48 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BROOKDALE NORTH FREMONTFACILITY NUMBER:
015601255
ADMINISTRATOR:EBONY (LADY) REEDFACILITY TYPE:
740
ADDRESS:38035 MARTHA AVETELEPHONE:
(510) 797-4011
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:40CENSUS: 31DATE:
07/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Lady ReedTIME COMPLETED:
10:45 AM
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On 07/30/2021 at 9:03am, Licensing Program Analysts (LPAs) A. O'Hollaren and J. Clancy-Czuleger arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator Lady Reed and explained the purpose of the visit.

During the inspection, LPAs toured facility including but not limited to common areas, hand washing stations, bedrooms, kitchen and courtyard. LPAs observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPAs observed PPE, food and paper supplies are sufficient. COVID-19 screening questions were maintained at the facility for all staff, residents, and visitors. Hand sanitizer is provided at facility entryway. Common areas are disinfected frequently throughout the day. A carbon monoxide detector was tested and was observed to be working. Smoke detectors are interconnected to the Fire Department.

During record review, LPAs observed facility has a copy of Mitigation Plan on file.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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