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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200355
Report Date: 06/06/2024
Date Signed: 06/06/2024 12:26:50 PM


Document Has Been Signed on 06/06/2024 12:26 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:FEASTER, NIARE DAWNFACILITY TYPE:
740
ADDRESS:18888 BOLLINGER CANYON RDTELEPHONE:
(925) 831-3964
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:110CENSUS: DATE:
06/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jennifer Gordon-Alvarez, Health and Wellness DirectorTIME COMPLETED:
12:45 PM
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On 6/06/24 at 10:45 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit due to receiving an Unusual Incident Report (UIR) of a resident having committed suicide. LPA met with Jennifer Gordon-Alvarez, Health and Wellness Director and explained the purpose of the visit.

During the visit LPA interviewed S1, reviewed R1's facility file and toured R1's room.

R1 was admitted to the facility on 11/14/23 from a rehab facility due to having suffered a stoke. Physician's Report dated 6/16/23 indicates that R1 was independent and could leave the facility unassisted. R1 also managed his own medications. The report also documented that R1 did not have any suicidal ideations.

S1 stated that R1 routinely took walks on the hill behind the facility. S1 stated that on 6/04/24 at around 5 p.m. she received a call from a friend of R1. The friend stated that he had called R1 numerous times throughout the day and haven't heard back from him. S1 searched for R1 and found him slumped over on the trail behind the facility. S1 observed a small handgun next to R1. S1 called 911, police and paramedics arrived and pronounced R1 decreased from an apparent suicide.

S1 filed an UIR and called the facility's LPA to inform her of the incident.

LPA toured R1's room with S1 and observed it to be neat and orderly with several personal items.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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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