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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200355
Report Date: 08/10/2022
Date Signed: 08/10/2022 03:37:14 PM


Document Has Been Signed on 08/10/2022 03:37 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: 45DATE:
08/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Akindele Omole, Executive DirectorTIME COMPLETED:
03:50 PM
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On 8/10/2022 at 1:40 PM, Licensing Program Analysts (LPAs) L. Francisco and P. Watson arrived unannounced to conduct Infection Control Inspection. LPAs met with Executive Director, Akindele Omole and Carolyn Appeal, and LPAs explained the purpose of the visit.

During the Infection Control Inspection, LPAs toured facility with Executive Director and Wellness Director including but not limited to front entrance, screening station, hand washing stations, a sample of apartments, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, and paper towel. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff.

At 3:05 PM, LPAs reviewed 5 staff records and 5 of 5 have TB test on file. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit. Exit interview conducted with Wellness Director. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
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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