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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601257
Report Date: 04/10/2024
Date Signed: 04/10/2024 02:48:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
02/27/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240227113854
FACILITY NAME:BROOKDALE DANVILLEFACILITY NUMBER:
075601257
ADMINISTRATOR:SEIFFERT, JASMINEFACILITY TYPE:
740
ADDRESS:400 W EL PINTADO RDTELEPHONE:
(925) 838-3020
CITY:DANVILLESTATE: CAZIP CODE:
94506
CAPACITY:42CENSUS: 21DATE:
04/10/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Executive Director, Teresa TruongTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not inform resident's physician of resident's change of condition.
Staff did not ensure resident's medication supply was available at the facility
INVESTIGATION FINDINGS:
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On 4/10/2024 at 1:20PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct complaint investigation and to deliver complaint findings for the above allegations. LPA met with Executive Director, Teresa Truong and explained the purpose of the visit.

During the investigation LPA interviewed the Executive Director and spoke with med-tech. While interviewing the Executive director, Teresa Truong confirmed that at the time of the complaint physicians were not being notified in a timely manner that is required by reporting requirements. ED also confirms the supply of medications was being mismanaged at the time. LPA interviewed med-tech who stated Health and Wellness director was in charge of medications and the availability of them and at the time Health and wellness director was not doing their job duty and medications were being overlooked. Health and Wellness director has been let go as a result

Report Continues on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
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-20240227113854
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2024
Section Cited
CCR
87465(a)(4)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The ... assistance in obtaining such care...with the following: The licensee shall assist residents ...as needed.

This requirement was not met as evidence by:
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Executive Director dismissed Health and wellness director and trained Med-techs on the proper medication protocols
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Based on interviews LPA was informed that previous Health and Wellness Director was not insuring the availability of medications.
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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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240227113854
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/10/2024
NARRATIVE
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LPA cited for CCR-87466 on complaint 15-AS-20240131134629 and will not be recited on this complaint.

Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3