015601255-12-8-2021-15-AS-KHOS-C9VQLP-20211220111617

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601255
Report Date: 12/08/2021
Date Signed: 12/08/2021 01:47:14 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
06/14/2021 and conducted by Evaluator Lisha Holmes

COMPLAINT CONTROL NUMBER: 15-AS-20210614114213

FACILITY NAME:	BROOKDALE NORTH FREMONT		FACILITY NUMBER:	015601255
ADMINISTRATOR:	EBONY (LADY) REED		FACILITY TYPE:	740
ADDRESS:	38035 MARTHA AVE		TELEPHONE:	(510) 797-4011
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	40	CENSUS: 27	DATE:	12/08/2021
		UNANNOUNCED	TIME BEGAN:	09:27 AM
MET WITH:	Ebony (Lady) Reed, Executive Director		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility prevented contact with resident’s family

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 12/08/2021 at 9:27 AM, Licensing Program Analysts (LPAs) L. Holmes and G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegation above. LPAs met with Staff, Cherie Herzog. Executive Director, Ebony (Lady) Reed arrived about 20 minutes later.

During the investigation, LPA interviewed staff, witnesses, and complainant. LPA obtained and reviewed staff schedules, resident roster, and resident's emergency contact information. Interview with witnesses revealed that family members were able to have FaceTime/in-person visits with residents. Witnesses stated that visits need to be scheduled with facility and temperature screening was conducted for in-person visits. Interview with staff indicated that residents were assisted with FaceTime visits during the timeframe July 2020 to February 2021.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

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 1