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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200355
Report Date: 07/15/2020
Date Signed: 07/15/2020 11:51:21 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BROOKDALE SAN RAMONFACILITY NUMBER:
079200355
ADMINISTRATOR:SHAWN MICHAEL CULLFACILITY TYPE:
740
ADDRESS:18888 BOLLINGER CANYON RDTELEPHONE:
(925) 831-3964
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:110CENSUS: 53DATE:
07/15/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Executive Director Shawn CullTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Delmundo called and spoke with LVN-Health and Wellness Director Alysa Serivida and Executive Director Shawn Cull. LPA explained that the reason for the call is regarding the death report submitted by the facility and received by Community Care Licensing on July 13, 2020. LPA further explained that LPA is doing case management via video conference.

Report indicated that on June 6, 2020 resident (R1) was going up to her apartment using the stairs when staff heard something hit the floor. Staff checked. R1 fell backwards and hit her head. Staff called 9-1-1 immediately. R1 was pronounced dead.

LPA conducted interviews and requested to have the following submitted before the end of the day today, July 15, 2020: Physician's Reports; LIC601 Identification and Emergency Information; Appraisal/Needs and Services Plan; Functional Capability Assessment; doctor's order of medications; Medication Administration Records

No deficiency cited on this day.

Exit interview and copy of this report provided via e-mail.
SUPERVISOR'S NAME: Isaac TaggartTELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2020
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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