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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601257
Report Date: 03/19/2026
Date Signed: 03/19/2026 01:22:16 PM

Document Has Been Signed on 03/19/2026 01:22 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 DANVILLEFACILITY NUMBER:
075601257
ADMINISTRATOR/
DIRECTOR:		TRUONG, TERESA HONG PHUCFACILITY TYPE:
740
ADDRESS:400 W EL PINTADO RDTELEPHONE:
(925) 838-3020
CITY:DANVILLESTATE: CAZIP CODE:
94506
CAPACITY: 42CENSUS: 18DATE:
03/19/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Executive Director, Cecily PalmaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 3/19/2026 Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit. LPA met with Resident Care Coordinator, Christine Montemayor and explained the purpose of the visit. Executive Director, Cecily Palma was notified and arrived at approximately 11:20am

On 10/3/2025 LPA A Gomez conducted a case management vist as a result of a self reported incident.During the visit on 10/3/2025 LPA observed residents room floors dirty and bathrooms unclean with dry fecal matter on the toilet in room 11. Operations Specialist stated that they are actively looking for a new maintenance and house keeping. LPA also observed that were not enough caregivers on shift. On 10/3/2025 there were 3 caregivers available, five out of twenty-three residents require a two person assist, facility states they were also hiring more care staff. LPA also observed facility common area/ activities area furniture (ie chairs and couches) in disrepair and damaged. LPA stated that they would return at a later date to cite for deficiencies observed and will now cite on todays date. LPA also observed on todays date dried blood on wall in room 18 and that common area chairs/sofas are in disrepair by being peeled/split on the cushions as well as the arm rests being soiled.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Alona Gomez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/19/2026 01:22 PM - It Cannot Be Edited


Created By: Alona Gomez On 03/19/2026 at 11:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE DANVILLE
FACILITY NUMBER: 075601257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2026
Section Cited
CCR
87470(a)(2)(A)

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(a) A licensee shall ensure that infection control...as follows:(2) Environmental cleaning...at a minimum, as follows:(A)Surfaces ... visibly soiled with...potentially infectious material.

This requirement was not met as evidence by:
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By POC Facility agrees to provide an in service to all staff and notify CCLD
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Based on LPAs observations the facility did not disinfect the visibly soiled surface in room 11. LPA observed that the surface had dried feces, dried blood on wall next to bed, and floors were unsanitary which posed a potential health and personal rights risk to residents in care.
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Type B
03/26/2026
Section Cited
CCR87411(a)

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(a) Facility personnel shall at all times be sufficient in numbers...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement was not met as evidence by:
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By POC facility agrees to submit staff schedules and proof of trainings of other staff available to provide care if neccessary. LPA will asses if staff available is sufficient and follow up with facility.
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Based on LPAs observations and record review facility care staff numbers is not suffient to meet the residents needs because on 10/3/2025 5 out of 23 residents require a two person assist and three caregivers and one medtech were on shift which posed a potential personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2026


LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 03/19/2026 01:22 PM - It Cannot Be Edited


Created By: Alona Gomez On 03/19/2026 at 12:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE DANVILLE
FACILITY NUMBER: 075601257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2026
Section Cited
CCR
87307(d)(2)

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(d) The following...shall apply to all facilities:(2) The premises shall be maintained in a state of good repair...

This requirment is not met as evidence by:
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By POC Facility will make a plan for repairs to furniture or relace and notify CCLD.
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Based on observation the facility did not maintain the furniture in a state of good repair by activities area sofas ripping at seams and exposing nails that pointed up which posed a potential safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2026


LIC809 (FAS) - (06/04)
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