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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200355
Report Date: 08/02/2023
Date Signed: 08/02/2023 04:30:47 PM

Document Has Been Signed on 08/02/2023 04:30 PM - It Cannot Be Edited

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:OMOLE, AKINDELE AFACILITY TYPE:
740
ADDRESS:18888 BOLLINGER CANYON RDTELEPHONE:
(925) 831-3964
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 110CENSUS: 50DATE:
08/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Niare Feaster, Executive DirectorTIME COMPLETED:
04:45 PM
NARRATIVE
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While at the facility conducting 10-day investigation related to complaint #15-AS-20230731144026, LPA observed CCL has not been about a change in the facility's Administrator.

Type B deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted with Executive Director and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
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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Document Has Been Signed on 08/02/2023 04:30 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/02/2023 at 03:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE SAN RAMON
FACILITY NUMBER: 079200355

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2023
Section Cited
CCR
87211(g)

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87211 Reporting Requirements
(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following:
(1) Name and residence and mailing addresses of the new administrator.
(2) Date he/she assumed his/her position.
(3) Description of his/her background and qualifications, including documentation of required education and administrator certification.
(A) A photocopy of the documentation is acceptable.
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By POC, Executive Director will send to CCL all required documents per Sec 87211(g).
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Based on record review conducted, Executive Director has been working at the facility since 1/15/2022 but failed to notify CCL which poses a potential risk to health and safety of clients under care.
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
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