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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200355
Report Date: 04/25/2024
Date Signed: 04/25/2024 04:41:42 PM

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
07/31/2023 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230731144026
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: 72DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Jennifer Gordon-AlvarezTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not follow proper reporting requirements
INVESTIGATION FINDINGS:
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On this day, LPA Luisa Fontanilla arrived unannounced to deliver finding for the above allegatoin and met with Jennifer-Gordon Alvarez. LPA explained to Alvarez the purpose of the visit.

During the course of investigation, LPA interviewed staff and reviewed records. S9 states R1 reported concerns regarding S8 inappropriate behavior to S9 and S5 on July 12, 2023. SOC 341 was created on July 28, 2023.

Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D.

Exit interview was conducted with Alvarez and Appeal Rights was provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
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 3
Control Number 15-AS-20230731144026
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: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2024
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D) Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence …

(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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By POC date, the Administrator will review cited section and submit certificate of understanding to CCL.
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This requirement is not met as evidenced by: Based on interviews and record review conducted, facility failed to report R1’s concerns regarding S8 inappropriate behavior to CCL within 7 days of occurrence which poses a potential risk to the health and safety of the clients under care. The incident was reported to S9 on 7/12/23. SOC 341 was created on 7/28/23.

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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: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
07/31/2023 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230731144026

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: 72DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Jennifer Gordon-AlvarezTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff do not provide proper mobility assistance to resident in care
Staff do not provide proper bathing assistance to resident in care
Resident's bedding is not changed frequently
Staff engaged in inappropriate interactions with resident in care
Facility does not have a proper Emergency Disaster Plan
INVESTIGATION FINDINGS:
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On this day, LPA Luisa Fontanilla unannounced to deliver findings on the above alleagtions and met with Jennifer Gordon-Alvarez. LPA explained to Alvarez the purpose of the visit.

Staff do not provide proper bathing assistance to resident in care
Based on R1’s Personal Service Plan (PSP), R1 has showers scheduled on Tuesday and Saturday. Interviews conducted with staff indicate that R1 was given bed baths as scheduled instead of showers. R1 confirmed with LPA that the night shift staff provide bed baths. Staff interviewed state that since R1 was unable to put weight on the toe without the hoyer lift, bed baths were provided.

Staff do not provide proper mobility assistance to resident in care
During the course of investigation, LPA interviewed six staff and Resident 1 (R1) and reviewed records.
Based on interviews and record review conducted, R1 has a doctor’s order for a hoyer lift upon discharge to the facility. R1’s Preplacement Appraisal indicates R1 needs maximum help in transferring in and out of bed and dressing, bathing, toileting. R1 requires a mechanical lift for all transfers. S6, who conducted the preplacement appraisal confirmed with LPA the order. Despite the doctor’s order, S6 states the order was never placed stating R1’s family declined the lift. The hoyer lift was ordered at a later time and got delivered on 6/20/2023.
Resident 1 (R1) confirmed with LPA during the interview that R1 declined the order for hoyer lift. R1 states that S10 promised R1 during admission that R1 does not need hoyer lift because the facility has “big and strong” staff to assist with transfers.

On 4/25/2024, LPA interviewed S10 who states that it was explained to R1 that there is a doctor’s order for hoyer. And that the hoyer lift will be used by two staff when transferring R1 because R1 was unable to put pressure on the foot. S10 states that due to the extra cost, the family refused hoyer lift. S10 denied promising R1 that hoyer lift is not needed because the facility has “big and strong” staff to assist with transfers.
continuation on Lic 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20230731144026
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: 04/25/2024
NARRATIVE
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Resident's bedding is not changed frequently

R1’s PSP indicates that R1’s laundry and housekeeping schedule is every Monday. Staff interviewed state R1’s beddings get changed as scheduled unless R1 refuses. And during bed baths, staff interviewed state if the sheet gets wet from the bed bath, they change the beddings.

Staff engaged in inappropriate interactions with resident in care

During the course of investigation, LPA interviewed staff who state that they have not worked with S8 for a long time. S6 states that all S6 knows about S8 is that S8 resigned from the facility due to an emergency that required S8 to go back to S8’s country of origin. And as far as S6 is aware, S6 treats residents good. However, S6 states S6 is not aware what happens once S8 is alone with the residents inside the room. S9 states S8 resigned from the facility in June 2023. LPA was unable to obtain contact information for S8.

Facility does not have a proper Emergency Disaster Plan

Based on interviews conducted with the Executive Director, the facility does annual emergency disaster training. Fire and elopement drills are conducted monthly. The facility’s last emergency disaster drill was conducted on May 25, 2023.

Based on interviews and record reviews conducted, the above allegations are unsubstantiated.

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



There are no deficiencies noted.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 1 of 1