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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601257
Report Date: 04/25/2024
Date Signed: 04/25/2024 02:25:24 PM


Document Has Been Signed on 04/25/2024 02:25 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:TRUONG, TERESA HONG PHUCFACILITY TYPE:
740
ADDRESS:400 W EL PINTADO RDTELEPHONE:
(925) 838-3020
CITY:DANVILLESTATE: CAZIP CODE:
94506
CAPACITY:42CENSUS: 24DATE:
04/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Executive Director, Teresa TruongTIME COMPLETED:
02:40 PM
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On 4/25/2024 at 1:30 PM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a Case Management visit in regards to an unusual incident report received 3/21/2024. LPA met with Executive Director, Teresa Truong and explained the purpose of the visit.

CCLD received an unusual incident report dated 3/21/2024 That stated that on 3/17/2024, at approximately 3:00pm and 8:00 pm, R1 was given the wrong dose of medication. On 3/18/2024, Medtech noticed the medication error and notified the Area nurse Manager. R1 was given 8 mg of Ativan at 3:00 pm and 8:00 pm. R1 order is Ativan 2mg: take 2 tablets by mouth three times a day. Physician and responsible parties were notified.

LPA spoke with Executive Director who stated that when the medication was renewed the milligrams per tablet went up and the Medtech(S1) did not notice. When giving R1 their medications they gave them the usual amount of tablets not noticing that because of the milligram increase they should have given less tablets. Executive Director acknowledged that it was an oversight and spoke with staff about the importance of paying attention to detail. A training was provided on Medication Procedures and Documentation on 3/20/2024. Medtech(S1) who gave the wrong dosage of medication was written up. Resident sustained no ill side effects.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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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