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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200355
Report Date: 06/04/2026
Date Signed: 06/04/2026 10:27:29 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/09/2026 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20260209082337
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: 67DATE:
06/04/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director, Lola BullockTIME COMPLETED:
10:35 AM
ALLEGATION(S):
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Staff did not ensure residents room was clean
INVESTIGATION FINDINGS:
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On 6/4/2026 at 9:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Lola Bullock, Executive Director.

On the allegation; Staff did not ensure residents room was clean

Staff interviews stated that the facility did not have a consistent or implemented procedure for logging housekeeping tasks when concerns arose. Staff reported noticing a smell in the resident’s room and checked the refrigerator, bathroom, and bedroom but were initially unable to locate the source. Record review showed one documented concern regarding R1’s room environment. On 11/9/2025, staff reported a “foul smell coming from her apartment” after checking the refrigerator and trash with no identifiable source found.

Continued on LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
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
Control Number 15-AS-20260209082337
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BROOKDALE SAN RAMON
FACILITY NUMBER: 079200355
VISIT DATE: 06/04/2026
NARRATIVE
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Continued from LIC 9099

The odor was later traced to food in the microwave, which had been obstructed from view. Maggots were removed, and the microwave was replaced. Staff stated a meeting was held afterward, and a daily housekeeping activity sheet was created and implemented to document completed and uncompleted cleaning tasks. Staff further reported that November was a difficult month due to the loss of multiple housekeepers, resulting in management filling in until additional hiring restored full housekeeping staffing levels. Housekeeping reportedly serviced rooms once a week unless notified of a spill or mess requiring additional cleaning.

Based on LPAs interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/09/2026 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20260209082337

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: 67DATE:
06/04/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director, Lola BullockTIME COMPLETED:
10:35 AM
ALLEGATION(S):
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Due to staff neglect, resident sustained pressure injuries
Staff did not answer residents calls for assistance timely
Staff did not follow Physicians’ orders
Staff left resident in soiled lines/clothing for an extended period of time
INVESTIGATION FINDINGS:
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On 6/4/2026 at 9:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Lola Bullock, Executive Director.

On the allegation; Staff did not answer residents calls for assistance timely

Record review showed frequent staff documentation that R1 was checked and assisted every 1–2 hours; however, a family report on 12/4/2025 stated concern that R1 was not being checked in a timely manner. Notes also reflected multiple instances where R1 refused care, which at times limited staff’s ability to provide timely assistance. The record contains no documentation of R1 using or attempting to use a call button or emergency device, and no references to call light or pendant response times.

Continued on LIC 9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
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-20260209082337
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BROOKDALE SAN RAMON
FACILITY NUMBER: 079200355
VISIT DATE: 06/04/2026
NARRATIVE
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Continued from LIC 9099-A

On the allegation; Due to staff neglect, resident sustained pressure injuries

Record review showed that R1 developed a pressure related wound requiring ongoing dressing changes and hospice involvement. Notes beginning 12/1/2025 indicated discomfort to the bottom, and by 12/4/2025 hospice staff were changing the wound dressing. On 12/7/2025, staff documented wound drainage and continued pain. R1 frequently refused repositioning, increasing her risk of skin breakdown. A low air loss mattress was ordered and delivered on 12/10/2025. On 12/17/2025, the wound dressing was found contaminated with BM and was changed; hospice continued providing wound care. R1 remained on hospice services until her passing on 12/19/2025.

On the allegation; Staff did not follow Physicians’ orders

Record review showed several updates to R1’s physician ordered medications. On 10/20/2025, Hydrocodone/Acetaminophen was ordered twice daily for pain, generating drug‑interaction alerts. On 11/12/2025, Furosemide 40 mg was ordered for ascites, and on 11/21/2025, hospice directed that it be discontinued. On 12/08/2025, Morphine Sulfate oral solution was ordered as a PRN for pain and shortness of breath. On 12/10/2025, a Fentanyl patch order was entered, which also triggered interaction alerts. Certain medication orders, including Hydrocodone/Acetaminophen on 10/27/2025 and 11/09/2025, were later removed or adjusted in response to R1’s refusals and changes in her hospice care plan.
Record review including the facility MAR, hospice collaboration notes, hospice EMR, and the Kaiser Physician’s Report—showed that R1’s physician and hospice orders were followed. Medications such as Norco, morphine, bowel regimen agents, oxygen, and wound‑care treatments were administered as ordered, with refusals documented, and discontinuation made only per hospice direction. Hospice notes consistently show orders communicated to facility staff and carried out during visits. No evidence was found of missed or ignored physician or hospice orders

Continued on LIC 9099-C...
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20260209082337
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BROOKDALE SAN RAMON
FACILITY NUMBER: 079200355
VISIT DATE: 06/04/2026
NARRATIVE
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Continued from LIC 9099-C

On the allegation; Staff left resident in soiled lines/clothing for an extended period of time

Staff interviews stated that residents receive laundry services once a week and are responsible for providing their own bed sheets. S1 reported that staff would change soiled sheets when found; however, this was sometimes difficult when a resident only had one set of sheets. S1 further explained that when a resident consistently soiled their bedding, the facility would request additional sheets from the family, though families did not always provide them. S1 added that the previous Wellness Manager often purchased spare sheets for residents who needed an extra set.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20260209082337
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE SAN RAMON
FACILITY NUMBER: 079200355
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2026
Section Cited
CCR
87303(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visit
This requirement is not met as evidenced by:
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The facility agrees to review the regulation and submit a letter of self certification along with the updated housekeeping check list to CCLD by POC date.
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Based on LPAs interview licensee did not comply with the section above by not cleaning a residents microwave which allowed maggots to form which poses a potential health, safety or personal rights risk to persons in 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6