<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601257
Report Date: 05/14/2024
Date Signed: 05/14/2024 10:04:17 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/22/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20231222120155
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: 25DATE:
05/14/2024
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Teresa Truong, Executive Director TIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure facility is kept in clean, safe sanitary conditions for residents in care.
Staff do not ensure resident care plans are followed.
Staff do not ensure adequate care and supervision is provided to residents in care.
Staff do not ensure reporting requirements are followed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5/14/2024 at 09:10AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Executive Director Teresa Truong.

On the allegation facility staff does not ensure facility is kept in clean, safe sanitary conditions for residents in care. Based on observations and interviews the facility did not clean up vomit from R1’s floor. LPA observed the mess on the floor and spoke with W1 who said that it has been there for at least a week, and the floors have not been moped to clean it.

On the allegation facility did not ensure resident care plans are followed. Based on record review and interviews the facility has not been putting the compression socks on R1 as instructed by his doctor and written in his care plan.
Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
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 6
Control Number 15-AS-20231222120155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BROOKDALE DANVILLE
FACILITY NUMBER: 075601257
VISIT DATE: 05/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
...Continued from 9099
On the allegation facility do not ensure adequate care and supervision is provided to residents in care. Based on record review and interviews the facility did not have enough staff. S1 stated that at the time of the complaint there was a shortage in staffing.

On the allegation facility staff do not ensure reporting requirements are followed. Based on record review and interviews the facility was not reporting incidents that were happening. S2 stated that S3 was responsible for reporting but she left the facility and other staff were unaware of the reporting process and reporting requirements.

Based on LPAs interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/22/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20231222120155

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: 25DATE:
05/14/2024
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Teresa Truong, Executive Director TIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
facility do not ensure residents are getting meals
facility does not ensure the facility has a certified administrator
facility do not ensure residents are always kept in clean dry clothing
Staff do not ensure medications are dispensed as prescribed for residents in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5/14/2024 at 9:10AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator_____.

On the allegation facility does not ensure the facility has a certified administrator. Based on record review and interviews the facility did lose their administrator with very little warning. S3 gave her notice two days before leaving company. S1 and other staff from the company worked to set up a plan to have a temporary Director until they were able to hire a new Director who was able to start one month later. S1 stated that they always had someone who had their administrator certificate come to the facility and assist while they were in this process.
On the allegation facility do not ensure residents are always kept in clean dry clothing. Based on record review and interviews the facility staff stated that when they notice someone has spilled or had incontinence they will finish or stop what they are doing and go to clean up that resident.

Continued on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20231222120155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BROOKDALE DANVILLE
FACILITY NUMBER: 075601257
VISIT DATE: 05/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
...Continued from 9099A

On the allegation facility do not ensure residents are getting meals. Based on interviews the facilities meals are served at regular times each day and if a resident oversleeps or is busy at a mealtime, they will save a plate for them. When asked about special meals or assistance S1 state that the care staff know who needs help with meals and that they have a list of who has dietary restrictions.

On the allegation Staff do not ensure medications are dispensed as prescribed for residents in care. Based on interviews the facility staff do dispense medication as prescribed for the residents and logs each dosage given in the medication log. Staff mark if a medication was refused or missed by a resident.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20231222120155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE DANVILLE
FACILITY NUMBER: 075601257
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2024
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not met as evidence by:
1
2
3
4
5
6
7
Facility has since hired a full time housekeeper. POC cleared
8
9
10
11
12
13
14
Based on observation, LPA observed vomit left uncleaned on the floor.
8
9
10
11
12
13
14
Type B
05/28/2024
Section Cited
CCR
87705(c)(4)
1
2
3
4
5
6
7
There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.

This requirement was not met as evidence by:
1
2
3
4
5
6
7
Facility has since hired additional staff and are fully staffed. POC cleared
8
9
10
11
12
13
14
Based on records review and observation LPA reviewed staff roster and staff schedules and observed that the facility did not have adequate staffing
8
9
10
11
12
13
14
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 15-AS-20231222120155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE DANVILLE
FACILITY NUMBER: 075601257
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2024
Section Cited
CCR
87211(a)(1)
1
2
3
4
5
6
7
A written report shall be submitted to the licensing agency and to the person responsible for the resident ... This report shall include...date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
This requirement was not met as evidence by:
1
2
3
4
5
6
7
The facility agrees to train additional staff on the reporting process. Proof of correction will be sent to CCLD by POC date.
8
9
10
11
12
13
14
Based on observation and interviews the staff working were unaware of how and where to report incidents to licensing.
8
9
10
11
12
13
14
Type B
05/28/2024
Section Cited
CCR
87705(c)(5)(A)
1
2
3
4
5
6
7
When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.
1
2
3
4
5
6
7
The facility agrees to review the regulation regarding care plans.Proof of correction will be sent to CCLD by POC date.
8
9
10
11
12
13
14
Based on records review and interveiws the facility was not following directions made by reisdents doctor.
8
9
10
11
12
13
14
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6