079200355-10-7-2021-15-AS-KHOS-CF9K6R-20220610073757

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200355
Report Date: 10/07/2021
Date Signed: 10/07/2021 03:48:29 PM

Unsubstantiated

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
03/12/2021 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20210312105400

FACILITY NAME:	BROOKDALE SAN RAMON		FACILITY NUMBER:	079200355
ADMINISTRATOR:	ANNA REDDY		FACILITY TYPE:	740
ADDRESS:	18888 BOLLINGER CANYON RD		TELEPHONE:	(925) 831-3964
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	110	CENSUS: 43	DATE:	10/07/2021
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Akindele Omole, Executive Director		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

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Resident left facility unsupervised
Resident not accorded dignity in their relationship with staff

INVESTIGATION FINDINGS:

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On 10/7/2021 starting at 10:20am, Licensing Program Analysts (LPAs) L. Francisco and J. Clancy-Czuleger arrived unannounced to conduct complaint investigation for the above allegation. LPAs met with Executive Director, Akindele Omole and explained the purpose of the visit.

During the course of investigation, LPAs obtained information, collected documents and interviewed 7 staff and 5 residents. Based on information obtained, it was alleged a resident walked out of the facility and crossed the street without assistance. Based on interview with 7 staff, 5 of 7 staff does not recall of incident where resident AWOL'd. No forthcoming information provided by reporting party.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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-20210312105400

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: 10/07/2021

NARRATIVE

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Information obtained alleging resident not accorded dignity in their relationship with staff. Based on interview with 5 residents, 5 of 5 residents stated staff are great and meet their needs. S1 stated if residents want to talk to Executive Director (ED) directly, ED's office door is always opened or residents can request staff for ED.

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.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

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