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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200355
Report Date: 10/07/2025
Date Signed: 10/07/2025 01:21:52 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
08/05/2025 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20250805091456
FACILITY NAME:BROOKDALE SAN RAMONFACILITY NUMBER:
079200355
ADMINISTRATOR:FEASTER, NIARE DAWNFACILITY TYPE:
740
ADDRESS:18888 BOLLINGER CANYON RDTELEPHONE:
(925) 831-3964
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:110CENSUS: 68DATE:
10/07/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director, Lola BullockTIME COMPLETED:
01:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not meeting residents toileting needs
Staff are not providing adequate food service
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/7/25 at 10:00 a.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver complaint investigation findings in regard to the allegations above. LPA met with Executive Director, Lola Bullock and explained the purpose of the visit.

On 8/7/2025, 9/12/2025, and 10/7/2025 LPA conducted interviews. On 9/12/2025 LPA also conducted observations at the facility. S1-S10 were interviewd. LPA also attempted to interview R1-R3.

Report continues on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
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 6
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
08/05/2025 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20250805091456

FACILITY NAME:BROOKDALE SAN RAMONFACILITY NUMBER:
079200355
ADMINISTRATOR:FEASTER, NIARE DAWNFACILITY TYPE:
740
ADDRESS:18888 BOLLINGER CANYON RDTELEPHONE:
(925) 831-3964
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:110CENSUS: DATE:
10/07/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director, Lola BullockTIME COMPLETED:
01:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not properly supervising residents who may be a fall risk
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/7/25 at 10:00 a.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver complaint investigation findings in regard to the allegations above. LPA met with Executive Director, Lola Bullock and explained the purpose of the visit.

On 8/7/2025, 9/12/2025, and 10/7/2025 LPA conducted interviews. On 9/12/2025 LPA also conducted observations at the facility. S1-S10 were interviewd and LPA discussed residents needs and services with Health and Wellness Director (HWD).
Report continues on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
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-20250805091456
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 SAN RAMON
FACILITY NUMBER: 079200355
VISIT DATE: 10/07/2025
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
On the allegation "Staff are not properly supervising residents who may be a fall risk" the following was found:

During interviews with staff on 8/7/2025 and 9/12/2025 were able to identify residents needs. LPA also observed sufficient coverage of staff on the day of the visits to meet the needs and services of residents. Based on observations of the staff schedule and staff on duty there is adequate supervision. LPA also briefly spoke to R3 who did not have any concerns with the care that they are receiving. On 9/12/2025 during PM shift LPA also tested call buttons in a random selection of rooms and staff were prompt to respond. Therefore the allegation "Staff are not properly supervising residents who may be a fall risk" is Unsubstantiated.

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.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20250805091456
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 SAN RAMON
FACILITY NUMBER: 079200355
VISIT DATE: 10/07/2025
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
PG. 2

On the allegation "Staff are not meeting residents toileting needs" the following was found:

During interviews with staff on 8/7/2025 and 9/12/2025 multiple staff reported that they have found residents wet and their beds "soaked" with urine during their shift. Staff made specific mention of R1, R2, and R3 being excessively wet on multiple occasions. During the interviews it was noted that residents are primarily found excessively wet at the start of the morning shift however it was mentioned that there have been occasions of excessive wetness on other shift. Multiple staff reported that they have reported concerns of residents incontinence needs not being met amongst other caregivers as well as leadership. LPA also attempted to interview R3 regarding incontinence but was unable to.Therefore the allegation of "Staff are not meeting residents toileting needs" is Substantiated.

On the allegation "Staff are not providing adequate food service" the following was found:
During interviews with staff on 8/7/2025 and 9/12/2025 there was a mixed review of the food being served at the facility. There were reports of the food being "ok", "good", and "healthy". There were also reports of the food "appearing under cooked" primarily the chicken. On 9/12/2025 the Health and Wellness Director (HWD) sampled the dinner meal of the day for the LPA and reported the food to have good flavor and quality. LPA observed the food that the HWD was sampling appeared to be of good quality. However upon inspection of the kitchen LPA observed that already prepared food to be served was not being stored properly and was left uncovered also sandwich supplies where also uncovered and not in use (ie. tomatoes, onion, lettuce, mayo, ect) . LPA also observed that there was a fly in the dinning/Kitchen area. LPA also inspected the food in the refrigerator/ freezer and observed some food in the refrigerator was moldy/expiring. LPA observed RAW chicken stored on top of produce in the refrigerator and open fish in the freezer. LPA also asked R3 about how they liked the food and they said it "sucked" but was unable to elaborate. Therefore the allegation of "Staff are not providing adequate food service" is Substantiated

report continued on LIC9099-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20250805091456
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 SAN RAMON
FACILITY NUMBER: 079200355
VISIT DATE: 10/07/2025
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
PG. 3

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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20250805091456
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 SAN RAMON
FACILITY NUMBER: 079200355
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2025
Section Cited
CCR
87625(b)(3)
1
2
3
4
5
6
7
(b)In addition .. the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry... from incontinence.
This requirement was not met as evidence by:
1
2
3
4
5
6
7
By POC date Health and Wellness Director agrees to submit a memo reminding staff of incontinent practices and provide a copy to CCLD
8
9
10
11
12
13
14
Based on interview with staff (S1-S10), the licensee did not comply with the section cited above in residents not being kept clean and dry from incontinence which poses a potential personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
10/14/2025
Section Cited
CCR
87555(a)
1
2
3
4
5
6
7
(a)The total daily diet shall ...be selected, stored, prepared and served in a safe and healthful manner.
This requirement was not met as evidence by:
1
2
3
4
5
6
7
By POC date Executive Director agrees to conduct a training regarding food storage and cleanliness procedures and notify CCLD
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above in having improperly stored and expired food in the kitchen which poses a potential personal rights risk to persons in care.
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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6