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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601257
Report Date: 06/14/2024
Date Signed: 06/14/2024 03:14:15 PM


Document Has Been Signed on 06/14/2024 03:14 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:
06/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director, Teresa TruongTIME COMPLETED:
03:26 PM
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On 6/14/2024 at 2:00 PM LPA A Gomez arrived to conduct a case management as a result of an unusual incident report received on 5/24/2024. LPA met with Executive Director, Teresa Truong and explained the purpose of the visit.

On Thursday, 5/23/2024, at 9:50 pm, staff heard screaming coming from room #9; staff ran to the room. and saw the R1 had a cane in hand attempting to hit R2 and R3 as they were on the floor.Staff were able to escort R1 out of the room, 911 was called for the R2 and R3, and they were sent to the hospital. Police were notified as well as all responsible parties.

LPA reviewed the Physicians report and Needs and services for R1. Prior to the incident R1 did not require a 1:1 and did not have a record of violent tendencies. ED states that after the incident R1 was provided a 1:1 and assessed to see if there was a higher level of care. R1 did have additional outburst with staff after incident and family agreed that the facility was not appropriate for R1's care needs. R1 no longer resides at the facility. R2 and R3 have returned from the hospital and are back to baseline. The facility continues to monitor them for any changes. Staff were additionally trained on care for residents with dementia and aggressive behavior.


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: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
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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