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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200070
Report Date: 11/10/2025
Date Signed: 11/10/2025 05:30:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
09/26/2024 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240926145838
FACILITY NAME:BRIDGE PROGRAM - PLEASANT HILLFACILITY NUMBER:
079200070
ADMINISTRATOR:CARSWELL, JOHNFACILITY TYPE:
735
ADDRESS:550 PATTERSON BLVD.TELEPHONE:
(925) 938-8050
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:64CENSUS: 52DATE:
11/10/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Michele Sheldon, Campus AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not ensure resident ate
Staff are not meeting residents needs
INVESTIGATION FINDINGS:
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On 11/10/2025 at 3:00 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Campus Administrator, Michele Sheldon, to deliver the findings of above allegations. LPA explained the purpose of the visit with the Administrator.

During the investigation, LPA obtained the following documents: Staff Roster, Resident Roster, Amazon Business Receipt, Staff Schedule (Aug '24/Sep '24), LIC 500 and R1's-R7's Admissions Face Sheets, Physician's Reports, Medication Lists, MARs, Medical Records for R1, Clinical Care Plan for R4 and R6, Progress Notes for August-September '24 and copy of Incident Reports if applicable.

LIC9099-C Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
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 10
Control Number 15-AS-20240926145838
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BRIDGE PROGRAM - PLEASANT HILL
FACILITY NUMBER: 079200070
VISIT DATE: 11/10/2025
NARRATIVE
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LIC9099-C (Page 2)

Allegation: Staff did not ensure resident ate
Finding: Substantiated

During the investigation, LPA conducted interviews with witnesses (W), staff (S), and reviewed resident (R1) documents.

R1 was admitted to the Bridge Program on 09/12/2024. Within two hours of admission, R1 eloped from the facility, requiring further intervention. On 09/17/2024, R1’s case manager notified the facility that R1 had been located following the elopement and was being transported to the Psychiatric Emergency Services (PES) at Contra Costa Regional Medical Center (CCRMC) for evaluation and stabilization. R1 returned to the Bridge Program on 09/20/2024. Program notes indicated that R1 attended dinner service that evening and ate their entire meal. No program notes were documented for 09/21/2024.

Witnesses (W1 and W2) reported that between 09/22/2024 and 09/24/2024, R1 consistently refused to eat. Staff (S3 and S4) corroborated these statements, adding that R1 was prompted at each meal but continued to refuse food.

W1, W2, S3, and S4 all stated that the SC initiated communication with county licensed clinicians due to concerns that R1 was decompensating and required professional evaluation.

On 09/24/2024, the A3 Crisis Team assessed R1 and placed R1 on a 5150 hold. Emergency services (911) were contacted, and R1 was transported to PES for further evaluation. R1 was diagnosed with Schizophrenia [F20.9] with psychosis and admitted to PES under Welfare and Institutions Code (WIC) as “Gravely Disabled.” R1 was discharged back to the Bridge Program on 10/24/2024 and remains under the program’s care.

LIC9099-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 15-AS-20240926145838
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BRIDGE PROGRAM - PLEASANT HILL
FACILITY NUMBER: 079200070
VISIT DATE: 11/10/2025
NARRATIVE
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LIC9099-C (Page 3)

LPA reviewed the following documentation: Progress Notes (dated 09/22/2024) R1 was prompted for lunch and dinner but refused to eat. Progress Notes (dated 09/23/2024) R1 was prompted for breakfast, lunch, and dinner but refused to eat. Plan of Care Note (dated 09/24/2024) R1 refused breakfast, and it was documented that R1 had not eaten any facility meals since the evening of 09/22/2024. Behavior Notes (BIRP) (dated 9/20/2024 and 09/23/2024), indicating the Service Coordinator (SC) and Care Team were notified of R1’s ongoing food refusal and related behaviors.

Allegation: Staff are not meeting residents needs
Finding: Substantiated

On 09/27/2024, LPA interviewed W1. W1 reported that R2 was not participating in the program and was only residing at the facility without engagement in services. W1 further stated that R4 refused to comply with vital sign checks and medication administration and alleged that the Administrator failed to address these concerns.

W1 stated that the facility did not provide towels or hygiene products to residents, which they believed contributed to a decline in residents’ mental health due to inadequate hygiene practices.

W1 additionally reported that R3 was frequently under the influence of methamphetamine and that there had been a smoke fire incident at the facility. W1 alleged that R4 was manipulated into refusing prescribed medications, which reportedly led to episodes of violent behavior, including attempts to assault staff and R5.

LIC9099-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 15-AS-20240926145838
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BRIDGE PROGRAM - PLEASANT HILL
FACILITY NUMBER: 079200070
VISIT DATE: 11/10/2025
NARRATIVE
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LIC9099-C (Page 4)

Finally, W1 stated that R6 became homeless after S2 allegedly failed to submit required paperwork following the expiration of a three-day hold.

S4 stated the facility is short-staffed on all shifts and unable to meet residents’ needs.
S4 reported that although the facility is consistently hiring, staff often resign due to lack of suitability for the position or to pursue higher wages and benefits elsewhere. S4 stated that on one Saturday they worked the AM shift with two other staff but were required to work a double shift due to lack of PM coverage. S4 further stated that support from the Administrator (S1) is lacking, reporting that during crises the Administrator is unavailable, in meetings, or remains in the office with the door closed.

LPA reviewed R1’s medical documents dated 09/16/2024 through 10/24/2024. Records indicate a diagnosis of Schizophrenia (F20.9). On 09/16/2024, R1 was admitted to Contra Costa Regional Medical Center Emergency Department for foot pain and social work consultation; discharged the same day. On 09/24/2024, R1 was placed on a 5150 hold by an A3 Crisis Therapist and transported to Psychiatric Emergency Services (PES). Medical records documented chief complaints of paranoia and aggressive behavior. Clinical notes indicated R1 presented with: Aggressive behavior and delusions, use of restraints and spit mask, internally preoccupied, over-controlled, non-verbal, and not contracting for safety. Records further indicated R1 had decompensated after a brief hospital stay at John Muir Health Behavioral Health Center.


LIC9099-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 15-AS-20240926145838
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BRIDGE PROGRAM - PLEASANT HILL
FACILITY NUMBER: 079200070
VISIT DATE: 11/10/2025
NARRATIVE
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LIC9099-C (Page 5)

Additional findings included: Mental health instability, medication noncompliance, refusal to eat, deficiencies in basic living skills, paranoia, isolation, grave disability and unemployed. Overall impairment severity was documented as severe. Interdisciplinary treatment plans were developed for inpatient hospitalization. Documentation noted R1’s behaviors represented: Danger to self or others, property destruction, inability to provide/utilize food, clothing, and shelter, and significant deterioration in functioning. Review of R1’s progress notes revealed no documentation that R1’s physician was notified of medication or meal refusals.

LPA reviewed R2’s Progress Notes (06/01/2024 – 09/29/2024), Appraisal Needs and Services (ANS) Plan (02/11/2025), and physician’s reports (01/24/2017 and 02/21/2025). Documentation indicated: Noncompliance with medications, group meetings, medical appointments, and IDT meetings. MARs (07/01/2024 – 10/31/2024) confirmed medication refusals. Physician’s reports since 2017 did not indicate prescribed medications. ANS noted R2 has been a resident since 2017 and previously ran out of medications while at a shelter.

LPA reviewed R3’s Progress Notes (06/02/2024 – 09/30/2024). Records indicated: History of Q30 high alert for drug use. Weekly positive drug tests for BUP, AMP, MDMA, and METH. Physician’s Report (dated 12/30/2023) documented a substance abuse problem and prior drug rehabilitation. Program/Behavior (BIRP) Notes (dated 09/22/2024) indicated R3 observed smoking through sliding door. Declined group meetings with county substance abuse counselor and AA meetings. BIRP note (dated 09/16/24) documented a fire outside R3’s room caused by smoking in an undesignated area; staff reminded R3 of designated smoking locations. R3 transported to CCRMC on 08/14/2024, 08/17/2024, and 09/18/2024 for medical clearance following positive drug tests.

LIC9099-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 10
Control Number 15-AS-20240926145838
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BRIDGE PROGRAM - PLEASANT HILL
FACILITY NUMBER: 079200070
VISIT DATE: 11/10/2025
NARRATIVE
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LIC9099-C (Page 6)

LPA reviewed R4’s Progress Notes (06/01/2024 – 09/30/2024), ANS (02/11/2025), physician’s report, and MAR. Records indicated: High alert for behavior related to medication changes. History of refusing prescribed Haldol 10mg. Communication with Physician (dated 06/21/2024) that doctor expressed concerns that by R4 refusing their Haldol medication that it would cause R4 to decompensate and that the doctor believed R4 was experiencing “psychotic’ symptoms. Further notes indicated that R4’s doctor requested that staff continue to keep track of R4’s sleep patterns and the amount of sleep that R4 was getting. Behavioral presentations included: Responding to internal stimuli, laughing/talking to self, arguing with residents and speaking to staff in a loud tone. LPA reviewed many entries that R4 was not sleeping at night and walking the hallways, sitting at the lobby talking loud to where other residents would complain that they couldn’t sleep. LPA reviewed ANS (dated 02/11/2025) that the care plan would be “symptom management” by R4 taking his medication prescribed by psychiatrist and weekly/monthly meetings with IDT to check progress.

LPA reviewed R5’s Progress Notes (dated 06/01/24 through 09/30/24), and ANS (dated 07/30/25). The records didn't reveal anything during this timeframe.

LPA reviewed R6’s Progress Notes (07/01/24 – 09/06/24), MAR (09/2024), and Clinical Care Plan Detail (09/01/23). Records indicated high-alert Q15 charting for suicidal ideation, suicide attempt, and fall risk. BIRP notes reflected medication refusals (07/27/24 – 08/01/24) in which R6 stated they were taking “too many meds.” On 08/01/24, R6 attended a doctor’s appointment and later reported to staff that their PM medications had been discontinued.

LIC9099-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
LIC9099 (FAS) - (06/04)
Page: 10 of 10
Control Number 15-AS-20240926145838
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BRIDGE PROGRAM - PLEASANT HILL
FACILITY NUMBER: 079200070
VISIT DATE: 11/10/2025
NARRATIVE
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LIC9099-C (Page 7)

However, staff documented (BIRP) that the After Visit Summary showed no medication changes. LPA did not review documentation indicating that R6’s physician(s) had been notified of the refusals. On 08/10/24, R6 was transported to PES and subsequently transferred to John Muir Behavioral Health in Concord on 08/11/24, where they remained hospitalized until discharge from the Bridge Program on 09/06/24. S2 documented a discharge note (09/06/24) stating that R6 was admitted to John Muir on 08/10/24 and that “the team determined that R6 would need to be discharged at this time for further care and placement.” LPA interviewed W3, who confirmed that R6 was admitted to John Muir on 08/10/24 and that the county closed their bed on 09/06/24.

Based on LPAs observations and interviews which were conducted and record reviews, 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.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 15-AS-20240926145838
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BRIDGE PROGRAM - PLEASANT HILL
FACILITY NUMBER: 079200070
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2025
Section Cited
CCR
85075.4(b)
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CCR 85075.4 Observation of the Client (b) The licensee shall provide assistance when observation reveals needs which might require a change in the existing level of service, or possible discharge or transfer to another type of facility.

This requirement is not met as evidenced by:
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Administrator will conduct a In-Service training with all staff on observation of the clients, reporting and activating A3 Crisis Team when necessary and will submit sign-in sheet with summary of training to
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Based on interviews, and record review the licensee did not comply with the section cited above by ensuring R1 ate and/or needed a change in the level of service which posed a potential health, safety or personal rights risk to persons in care.
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CCLD by POC due date.
Type B
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Section Cited
CCR
80072(a)(2)
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80072 Personal Rights
a) …each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations… to meet his/her needs.

This requirement is not met as evidenced by:
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Administrator will conduct a In-Service training with all staff on personal rights, observation, and physician notification requirements, medication compliance and personal care needs
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Based on interviews and record reviews, the licensee did not comply with the section cited above by ensuring residents’ needs, R1-R6, were met in the areas of supervision, hygiene, medication compliance, and physician notification. Residents were observed or reported to have unmet personal care needs, untreated mental health symptoms, and unsafe living conditions which poses a potential health, safety or personal rights risk to persons in care.
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and will submit sign-in sheet with summary of training to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
LIC9099 (FAS) - (06/04)
Page: 9 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
09/26/2024 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240926145838

FACILITY NAME:BRIDGE PROGRAM - PLEASANT HILLFACILITY NUMBER:
079200070
ADMINISTRATOR:CARSWELL, JOHNFACILITY TYPE:
735
ADDRESS:550 PATTERSON BLVD.TELEPHONE:
(925) 938-8050
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:64CENSUS: 52DATE:
11/10/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Michele Sheldon, Campus AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff are manipulating resident
Staff did not ensure they were not out of ratio

INVESTIGATION FINDINGS:
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Allegation: Staff are manipulating resident
Finding: Unsubstantiated

LPA reviewed documents for R4 and documents did not reveal any kind of manipulation to get R4 to take their medications.

Allegation: Staff did not ensure they were not out of ratio
Finding: Unsubstantiated

S3 stated that S1 frequently reassigns staff, moving personnel from the Bridge Program to cover shifts in the Pathway Program. According to S3, the Pathway Program is staffed with only one employee on weekends.

LIC9099-C Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 15-AS-20240926145838
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BRIDGE PROGRAM - PLEASANT HILL
FACILITY NUMBER: 079200070
VISIT DATE: 11/10/2025
NARRATIVE
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LIC9099-C (Page 10)

S3 further stated that S2 does not update the staff schedule, which creates the appearance of adequate coverage when staffing levels are, in fact, insufficient. S3 reported that S2 previously asked them, “Why haven’t you found coverage?”

As an example, S3 referenced 09/28/2024, when S5, S8, and S9 were scheduled to work in the Bridge Program. S3 reported that both S8 and S9 had requested the day off, leaving only S5 scheduled. S3 stated that S1 has not addressed ongoing staffing concerns in either the Bridge Program or the Pathway Program.

LPA reviewed the Bridge Program staff schedules for August and September 2024.
On 09/28/24 during the PM shift, only one staff member was scheduled. Two staff members were off, one staff member called out sick, and the on-call staff member was unavailable. With a program capacity of 64 residents, this resulted in a staff-to-resident ratio of 1:64. On 10/04/24, the census was 60 residents. LPA reviewed R1-R6 physician’s reports which did not indicate that they required direct care staff to assist with activities of daily living (ADL’s).


Although the allegations may have happened or is valid, there is 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 10