075601257-11-27-2023-15-AS-AGOZ-CXYTX3-20231127140627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601257
Report Date: 11/27/2023
Date Signed: 11/27/2023 02:06:40 PM

Document Has Been Signed on 11/27/2023 02:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	BROOKDALE DANVILLE		FACILITY NUMBER:	075601257
ADMINISTRATOR:	GLENDA BERTUCCI		FACILITY TYPE:	740
ADDRESS:	400 W EL PINTADO RD		TELEPHONE:	(925) 838-3020
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94506
CAPACITY:	42	CENSUS: 24	DATE:	11/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jasmine Seiffert, Director		TIME COMPLETED:	02:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) A. Gomez and Licensing Program Manager (LPM) Y Flores-Larios arrived unannounced to conduct 1-Year Annual Required visit on this date starting at 9:30am. LPA was greeted by Executive Director (ED), Jasmine Seiffert. Health and Wellness Director Cheyenne Flores arrived at approximately 11:00AM during the tour. LPA and LPM toured facility with Executive Director including but not limited to random residents rooms, kitchen, common area and dining area. There were no accessible bodies of water. Hallways and passages were free of obstruction. Comfortable room temperature was maintained at 71 degrees F. Hot water temperature was tested at 115.8 degrees F in one of the bathrooms. Refrigerator temperature measured at 36.3F and Freezer measured at -3F. One week supply of nonperishable and 2-day supply of perishable foods were available and in compliance with regulations. Employee's files and residents files and a sample of medications were reviewed. Employees were fingerprint cleared. Centrally stored medications were locked in medication room. LPA observed a sample of medication. The facility had a written emergency disaster plan dated 11/27/2023. Disaster drill was last conducted on 09/21/2023. Smoke detector and sprinklers were observed throughout facility. Fire extinguisher was last serviced 9/12/2023. ED holds current administrator certificate that expires 7/22/2024 The following deficiencies were observed: At approximately 9:55AM during resident file review R4's file was missing Safeguards for Property/Valuables, Consent Form, and Personal Rights. At approximately 11:50AM during employee file review all employee files were observed incomplete. At approximately 11:55AM during employee file review it was observed that required staff are missing first aid training.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE DANVILLE	FACILITY NUMBER: 075601257
	VISIT DATE: 11/27/2023

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 12/04/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate
Updated facility sketch

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/27/2023 02:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE DANVILLE	FACILITY NUMBER: 075601257
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review of five staff, the licensee did not comply with the section cited above in having incomplete employee files for 5 of 5 employees records reviewed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/04/2023
	Plan of Correction
1 2 3 4	By POC date Executive Director agrees to review and update all employee files and provide a checklist of required documents for each file to CCLD.

Type B

Section Cited

CCR

87506(b)

Resident Records

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in having R4's file missing the consent form and Appraisal of Needs and Services plan which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/04/2023
	Plan of Correction
1 2 3 4	By POC date Executive Director agrees to review resident file and update all required forms and submit a self certification to CCLD.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 11/27/2023 02:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE DANVILLE	FACILITY NUMBER: 075601257
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review of five staff, the licensee did not comply with the section cited above in not having the required staff first aid certified which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/04/2023
	Plan of Correction
1 2 3 4	By POC date Executive Director agrees to have all required staff first aid trained and certified and submit certificates to CCLD.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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