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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 01:17:26 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
01/31/2024 and conducted by Evaluator Alona Gomez
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240131134629
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:
11:00 AM
MET WITH:Executive Director, Teresa TruongTIME COMPLETED:
01:28 PM
ALLEGATION(S):
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Staff do not ensure resident's hyigene is being met.
Staff do not safe guard resident's personal items.
Staff lock residents out of their bedrooms.
Staff do not ensure reporting requirements are followed.
Insufficient staffing to ensure adequate care and supervision is provided to residents in care.
INVESTIGATION FINDINGS:
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On 4/10/2024 at 11:00AM, 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 invesgetation LPA interviewed the Executive Director, care staff, and activities coordiantor. LPA also toured the facility icluding the activies area, Laundry room, and random residents rooms.

While interviewing the Exectuitive director, Teresa Truong confirmed that at the time of the complaint there was a shortage in staffing, and that residents hygine needs and care needs were not able to be met. Executive Director also confirmed that responsible parties were not being notified in a timely manner that is required by reporting requirements. Executive Director acknowledged that residents clothing was getting mixed up.

Report continues on LIC 9099-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 5
Control Number 15-AS-20240131134629
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 interviewed S1 in regards to residents personal items not being safeguarded. S1 stated that in the laundry room they personally know which clothes belongs to who but that newer caregivers do not. LPA also observed in the laundry room clothing not delegated to specific residents. LPA observed that there is now a system in place to manage clothing for residents but that it is not currently being utilized.

LPA interviewed Activities Coordinator. Activities Coordinator confirmed that at the time of the complaint there was a shortage in staffing but that now it is starting to get better, and that residents care needs were not able to be met. Activities Coordinator also confirmed that they knew that responsible parties were not being notified in a timely manner that is required by reporting requirements. Activities Director also confirmed that sometimes residents clothing gets mixed up.

While touring the facility LPA observed residents doors locked and that a majority of residents did not have their own key to get in. Executive director stated that when she arrived that was already the system in place and that they were looking to change it. Activities coordinator stated that doors are locked because some residents have wandered into other residents room and taken their belongings.


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: 2 of 5
Control Number 15-AS-20240131134629
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
87468.1
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Personal Rights of Residents in All Facilities

This requirement is not met as evidenced by:
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By POC date Executive Director agrees to have all residents’ rooms unlocked and give them a key, and self-certified that Executive Director understand resident personal rights by the and notify CCLD.
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Based on observation and interviews residents rooms are locked and most residents do not have a key and must ask to get let in which poses a potential health and safety risk to the persons in care. .
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Type B
04/19/2024
Section Cited
CCR
87217(b)
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Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff... This requirement is not met as evidence by:
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By POC date Facility has agreed to develop and implement plan to better safeguard resident's belongings in the future and notify to CCLD
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Based on investigation, licensee did not comply with the section cited above by not safeguarding resident's belongings which poses a potential health and safety risk to the persons 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.
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: 3 of 5
Control Number 15-AS-20240131134629
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
87705(c)(4)
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Licensees who accept and retain residents with dementia shall be responsible for... the following: There is an adequate number of direct care staff to support each resident’s ... needs as identified in his/her current appraisal.

This requirement is not met as evidence by:
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Executive Director has hired additional staff to meet care and hygiene needs of residents
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Based on observation and interviews there was not adequate staffing to meet residents needs.
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Type B
04/19/2024
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical ... such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidence by:
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Executive Director dismissed staff not reporting properly and a traing was provided.
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Staff was not notifing residents responsible party ofchanges in residents conditions
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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: 4 of 5
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
01/31/2024 and conducted by Evaluator Alona Gomez
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240131134629

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:
11:00 AM
MET WITH:Executive Director, Teresa TruongTIME COMPLETED:
01:28 PM
ALLEGATION(S):
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Resident sustained an unexplained fracture while in care.
Staff leave residents soiled for an extended period of time.
Staff does not provide activities to residents in care.
INVESTIGATION FINDINGS:
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On 4/10/2024 at 11:00AM, 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 invesgetation LPA interviewed the Executive Director, care staff, and activities coordiantor. LPA also toured the facility icluding the activies area.LPA observed Activities being done on multiple visits as well as activities Calandar. S1, ED, and Activities coordinator confirm that activies are scheduled throughout the day. LPA was unable to find any proof or suggestion of residents being left soiled for extended periods of time. Based on complaint and reports LPA could not determine that fracture happened while in care.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
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: 5 of 5