079200355-2-7-2025-15-AS-KHOS-DFHPV2-20250407113825

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200355
Report Date: 02/07/2025
Date Signed: 02/07/2025 10:30:19 AM

Unsubstantiated

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
08/07/2024 and conducted by Evaluator Alona Gomez

COMPLAINT CONTROL NUMBER: 15-AS-20240807105106

FACILITY NAME:	BROOKDALE SAN RAMON		FACILITY NUMBER:	079200355
ADMINISTRATOR:	FEASTER, NIARE DAWN		FACILITY TYPE:	740
ADDRESS:	18888 BOLLINGER CANYON RD		TELEPHONE:	(925) 831-3964
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	110	CENSUS: 80	DATE:	02/07/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Niare Feaster, Executive Director (ED).		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Illegal eviction

INVESTIGATION FINDINGS:

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On 2/7/2025 at 9:30AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct an investigation and deliver findings. LPA met with Niare Feaster, Executive Director (ED).

During the course of the investigation LPA conducted interviews and reviewed available files. ED states that R1 was not able to return to the facility because they had a stage 3 wound and that they told R1 the wound needed to heal before retuning. LPA interviewed R1 as well and R1 stated that the wound was staged at a 3 by one physician and a 2 by another.

Report continues on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240807105106

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: 02/07/2025

NARRATIVE

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LPA also interviewed the health and wellness director (HWD) who stated that R1 was told that they could not return to the facility with a stage 3 wound. ED and HWD both stated that the resident could return once the wound was no longer a stage 3. There was no documentation available for the LPA to review the official diagnosis of the wound. Title 22 states, "(a)Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:(1)Stage 3 and 4 pressure injuries". R1 never received an official eviction letter and relatives removed R1's belongings. Therefore the allegation "Illegal eviction" 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.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025

LIC9099 (FAS) - (06/04)

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