079200355-3-27-2025-15-AS-KHOS-DFXKGN-20250421075348

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200355
Report Date: 03/27/2025
Date Signed: 03/27/2025 02:20:15 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
11/22/2024 and conducted by Evaluator Alona Gomez

COMPLAINT CONTROL NUMBER: 15-AS-20241122153441

FACILITY NAME:	BROOKDALE SAN RAMON		FACILITY NUMBER:	079200355
ADMINISTRATOR:	FEASTER, NIARE DAWN		FACILITY TYPE:	740
ADDRESS:	18888 BOLLINGER CANYON RD		TELEPHONE:	(925) 831-3964
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	110	CENSUS: 74	DATE:	03/27/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director, Lola Bullock		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Facility staff did not notify responsible party of change in condition
Facility staff serve poor quality food

INVESTIGATION FINDINGS:

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On 3/27/2025 at 9:00AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct an investigation and deliver findings. LPA met with Executive Director, Lola Bullock.

During the course of the investigation LPA conducted interviews, toured facility, observed the Kitchen/food, and reviewed available files. LPA interviewed S3, S4, S5, S6, and Health and Wellness Director (HWD)

Report continues on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

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-20241122153441

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE SAN RAMON	FACILITY NUMBER: 079200355
	VISIT DATE: 03/27/2025

NARRATIVE

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In regard to the allegations "Facility staff did not notify responsible party of change in condition " and "Facility staff serve poor quality food "LPA interviewed S3, S4, S5, S6, and Health and Wellnes Director. S3 was not a staff member at the time of R1's admission but stated that the quality of the food is good. S3 described the food as really good. S3 states that the menu choices are good. S3 has eaten the food and says that they are good; sometimes a little bland but nothing that salt and pepper cant fix. S4 stated that the resident never expressed unhappiness to them about anything. States that when resident would complain about the food they would say it sucks and that they would just agree with the resident . States that they have had the food a few times but that it was nothing memorable. S5 states that R1 never expressed any information about their private life. States that the R1 seemed happy. States that R1 would talk about problems with their jobs and going to court with their spouse but that they would be smiling when discussing it. S5 states that they were surprised to find out about R1 incident. States that R1 would complain about the food and quality and that they(S5) would apologize. S5 states that they have tried the food and that they do not like it. States the food is bland, tuff, and greasy. S6 states that they are trained to look for a change in behavior but was unable to specify in regard to mental health. S6 states that they heard about R1's incident and that when looking at the chart they could see that they had a history of depression. However S6 did not ever work with R1. States that it is very common for residents to complain about the food. States that residents complain about the meat being dry and tough. When LPA interviewed HWD they stated that R1 did not exhibit any change in their routine and that when they(R1) were admitted they were already going through stressors and it was not something new that occurred while at the facility. HWD states that R1 was an independent resident and also a private person. R1 would talk about what they were dealing with in life but never expressed being distressed. HWD states that on the day of the incident with R1 there was no change in their routine. HWD states that R1 had a therapist that they would work with and observed R1 utilizing coping mechanisms such as taking walks.

Report Continues on LIC9099-C

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20241122153441

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE SAN RAMON	FACILITY NUMBER: 079200355
	VISIT DATE: 03/27/2025

NARRATIVE

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LPA reviewed the 602 for R1 and observed that they did not have a diagnosis of depression and had a secondary diagnosis of anxiety. On 12/16/2024 LPA observed the food being served to the residents and utilized the Business Manager as a taste tester. The food observed was beef stew, rosemary chicken, bbq chicken, lasagna, and carrots. LPA cut each piece and had no difficulty. The business manager sampled each item and stated that they were easy to chew and had a pleasant taste. LPA asked the chef how each item was seasoned and the chef showed the LPA a variety of seasonings and stated that they also used low sodium seasoning. The food looked appetizing and had a pleasant smell. LPA also observed table salt and pepper available at all dining tables for use. On 3/27/2024 LPA briefly spoke with a R3, R4, and R5 during lunch hour who all stated that they like the food at they facility and have no complaints. Based on interviews, observations, and record reviews the allegations are UNSUBSTANTIATED.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC9099 (FAS) - (06/04)

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