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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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
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)
Page: 1 of 2


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 (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: 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-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
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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