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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601257
Report Date: 07/17/2020
Date Signed: 07/17/2020 12:00:42 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
11/01/2019 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20191101104256
FACILITY NAME:BROOKDALE DANVILLEFACILITY NUMBER:
075601257
ADMINISTRATOR:MORALES, CLAUDIAFACILITY TYPE:
740
ADDRESS:400 W EL PINTADO RDTELEPHONE:
(925) 838-3020
CITY:DANVILLESTATE: CAZIP CODE:
94506
CAPACITY:42CENSUS: 24DATE:
07/17/2020
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Glenda Bertucci, Executive DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Residents needs were not met.
Facility failed to refill resident's medication.
INVESTIGATION FINDINGS:
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13
On 7/17/2020 at 11:35am, Licensing Program Analyst (LPA) L. Francisco contacted facility to deliver complaint findings for the above allegations via tele-visit due to shelter in place directed by the Governor. LPA conducted tele-visit via facetime with Executive Director, Glenda Bertucci.

During the course of investigation, LPA obtained information, collected documents and interviewed staff. Based on information obtained from reporting party, Residents needs were not met. An interview with 2 of 2 staff provided conflicting information. S1 stated an ice pack is given according to doctor’s order. However, S2 stated no doctor’s order is needed when resident’s requests for an ice pack. According to S2, R1 has a device where ice can be inserted. LPA was unable to prove or disprove allegation. Incident occurred in memory care and LPA was unable to interview residents and obtain additional information.

REPORT CONTINUES ON 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
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 3
Control Number 15-AS-20191101104256
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 DANVILLE
FACILITY NUMBER: 075601257
VISIT DATE: 07/17/2020
NARRATIVE
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A complaint received alleging facility failed to refill resident's medication. Based on interview with 1 of 2 staff, R1 was under Omnicare. According to S2, R1’s medication was prescribed as needed. Once a medication is to be refilled, each medication would be tagged and submitted to Omnicare as long as there is a prescription order. However, if medication is empty, S2 stated it is because there was no new prescription prescribed by the physician.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of report will be emailed.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
11/01/2019 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20191101104256

FACILITY NAME:BROOKDALE DANVILLEFACILITY NUMBER:
075601257
ADMINISTRATOR:MORALES, CLAUDIAFACILITY TYPE:
740
ADDRESS:400 W EL PINTADO RDTELEPHONE:
(925) 838-3020
CITY:DANVILLESTATE: CAZIP CODE:
94506
CAPACITY:42CENSUS: 24DATE:
07/17/2020
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Glenda Bertucci, Executive DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to provide refund.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 7/17/2020 at 11:35am, Licensing Program Analyst (LPA) L. Francisco contacted facility to deliver complaint findings for the above allegations via tele-visit due to shelter in place directed by the Governor. LPA conducted tele-visit via facetime with Executive Director, Glenda Bertucci.

During the course of investigation, LPA obtained information, collected documents, interviewed staff. A complaint received alleging facility failed to provide refund. However, based on record review, a refund request was processed on 10/25/2019. It was revealed by reporting party that a check was received in the mail on 11/6/2019. Although the refund was not given in a timely manner, the refund was provided.

This agency has investigated the complaint alleging facility failed to provide refund. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report will be emailed.





Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3