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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200355
Report Date: 01/26/2026
Date Signed: 01/26/2026 04:54:30 PM

Document Has Been Signed on 01/26/2026 04:54 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BROOKDALE SAN RAMONFACILITY NUMBER:
079200355
ADMINISTRATOR/
DIRECTOR:		FEASTER, NIARE DAWNFACILITY TYPE:
740
ADDRESS:18888 BOLLINGER CANYON RDTELEPHONE:
(925) 831-3964
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 110CENSUS: 70DATE:
01/26/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Executive Director, Lola BullockTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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On 1/26/2026 at 9:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director (ED), Lola Bullock and explained the purpose of the visit. The facility’s fire clearance was approved for 82 non-ambulatory and 28 ambulatory on the third floor.

LPA toured the facility with ED including but not limited to 7 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 68 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 104.8, 107.6, and 108 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. Refrigerator temperature: 39 Freezer temperature:0 There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications are locked and inaccessible to residents in care.

Emergency disaster plan last reviewed 3/10/2025. Emergency disaster drill conducted 1/16/2026 .First aid kit observed to be complete. Fire Extinguishers last serviced 3/6/2025.

At 12:40pm, LPA reviewed 5 residents records. At 1:00pm, LPA reviewed 5 staff records and 1 of 5 have current first aid training and 5 of 5 are associated to the facility. LPA reviewed a sample of resident’s medications.

Report Continues on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Alona Gomez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 01/26/2026 04:54 PM - It Cannot Be Edited


Created By: Alona Gomez On 01/26/2026 at 04:11 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: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having 2 pairs of unlocked scissors in a common area unattended and stainless steel cleaner in residents available laundry rooms which poses an immediate safety risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
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Items removed POC clear
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/26/2026 04:54 PM - It Cannot Be Edited


Created By: Alona Gomez On 01/26/2026 at 04:11 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: 01/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 5 staff records review not having valid first aid which poses a potential safety and personal rights risk to persons in care.
POC Due Date: 02/10/2026
Plan of Correction
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By POC facility agrees to have all required staff complete first aid training and update their files and notify CCLD
Type B
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having food improperly stored throughout the kitchen which poses a potential health and personal rights risk to persons in care.
POC Due Date: 02/10/2026
Plan of Correction
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By POC Facility agrees to have all kitchen staff retake state approved food handlers/ expectation training, develop an after meal kichen checklist, and notify CCLD
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Alona Gomez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2026


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/26/2026
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • LPA observed unlocked scissors in activity space unattended and unlocked stainless steel cleaner in resident laundry rooms
  • LPA observed food being improperly stored in kitchen
  • LPA observed that 4/5 staff records reviewed did not have the required first aid training.


***Civil Penalty assessed $250 for repeat violation in 12 month period***

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 2/10/2026:



LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Updated Facility sketch
Current Administrator’s Certificate

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.



Exit interview conducted. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Alona Gomez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2026
LIC809 (FAS) - (06/04)
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