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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601255
Report Date: 12/09/2022
Date Signed: 12/09/2022 10:32:31 AM


Document Has Been Signed on 12/09/2022 10:32 AM - It Cannot Be Edited

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:ANGIE R. CHANEYFACILITY TYPE:
740
ADDRESS:38035 MARTHA AVETELEPHONE:
(510) 797-4011
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:40CENSUS: 22DATE:
12/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:ANGIE R. CHANEY, AdministratorTIME COMPLETED:
10:40 AM
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On 12/9/2022, at 9:10AM, Licensing Program Analysts (LPAs) L. Fici and J. Clancy-Czuleger arrived unannounced to conduct a case management visit for an incident that occurred on 11/8/2022. LPAs was greeted by ANGIE R. CHANEY, Administrator (ADM) and explained the purpose of visit.

LPAs received an Soc341 that was submitted to CCL on 11/14/2022. LPAs interviewed ADM regarding the incident. ADM verified that there was no injuries that the resident sustained, nor any bruising or marks on residents body. No pictures or videos were taken of the incident. Facility held an investigation on 11/8/2022 and investigation closed on 11/8/2022. The companion of the resident was from Glenmoor home care and was working one on one with resident. Companion of the resident is no longer allowed in Brookdale North Fremont as of 11/8/2022 because of the incident that occurred.


No deficiencies cited during visit.


Exit interview conducted with administrator, and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
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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