079200355-4-18-2025-15-AS-KHOS-DG6HQ9-20250428062333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200355
Report Date: 04/18/2025
Date Signed: 04/18/2025 10:56:03 AM

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
01/09/2025 and conducted by Evaluator Alona Gomez

COMPLAINT CONTROL NUMBER: 15-AS-20250109160645

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: 73	DATE:	04/18/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director, Lola Bullock		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Improper eviction
Resident needs are not being meant
Staff left resident in soiled diaper
Facility is not providing services that are being charged
Facility is short staffed
Facility is not proving resident proper meal
Resident is being isolated
Resident room is being used as staff break and or storage room

INVESTIGATION FINDINGS:

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On 4/18/2025 at 9:00AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver complaint findings for the above allegations. LPA met with current Executive Director, Lola Bullock and explained the purpose of the visit.

During the investigation LPA interviewed staff, residents, reviewed care plans, admissions agreements, physicians reports for R1, toured facility, and reviewed documents.

Report continues on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025

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-20250109160645

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: 04/18/2025

NARRATIVE

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On the allegations “Improper eviction” “Resident needs are not being meant” “Staff left resident in soiled diaper” “Facility is not providing services that are being charge” “Facility is not proving resident proper meal” “Resident is being isolated” “Resident room is being used as staff break and or storage room” “Facility is short staffed” the following was found:
On 01/14/2025, LPA conducted interviews with R1 and the Executive Director at the time Niare Feaster (ED), reviewed documentation including R1’s admission agreement, care plan dated 10/13/2023, physician’s report dated 04/18/2024, facility billing records, eviction notice, and staff schedules. Facility observations were also conducted. R1 stated they feel there are not enough staff and expressed a desire for more one-on-one interaction, including being accompanied to the activities area every Wednesday at 1:00 PM. R1, who identifies as largely independent, shared they self-administer medication and often decline bathroom assistance. They clarified they do not receive diapering services as part of their care plan and care plan reflects that they do not require incontinence care. R1 reported requiring nighttime toileting assistance due to wheelchair access challenges. R1 also shared concerns about having occasionally forgotten to request meals, resulting in limited options such as toast or pie. R1 expressed dissatisfaction with being billed for services such as oxygen management and bathing, which they believe are not provided.

Review of records showed R1 was admitted on 10/13/2023, with a base rate of $7,413.00 per month. The total amount billed through February 2024 was $46,630.62 including late fees, with only two successful payments made since admission, as reflected in the payment history. The ED explained that the oxygen service billed is the facility’s base rate for residents with oxygen, which includes documentation but no hands-on management or intervention. ED stated that toileting assistance remains on the service plan, however R1 seldom uses it and has declined its removal.

Report continues on LIC9099-C

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20250109160645

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: 04/18/2025

NARRATIVE

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Continued from LIC9099-C

Regarding the eviction, a 30-day notice to quit was issued on 02/02/2024 for non-payment of rent. Staff schedules for February and March 2024, were reviewed by LPA and LPA observed that enough staff were scheduled. LPA also observed an adequate amount of staff at the time of both visits. While R1 reported feeling that more staff would improve their experience, interviews and documentation confirmed no lapses in care or supervision. Observations conducted during the facility visit found R1’s room appropriately maintained and free of any signs it was being used for staff breaks or storage. There were no indications of inappropriate use of the resident’s private space. There was no evidence to support the allegation that staff left R1 in a soiled diaper, and this is further unsupported by the fact that R1 does not receive diapering assistance as part of their care plan. Regarding meals, kitchen staff reported that residents must request meals outside of scheduled times and that snacks, including pie, are available when full meals are not requested. R1 stated that they do forget to order meals sometimes and only wants toast or other small items from the options available. Finally, R1 stated that they remain in their room by choice due to pain and mobility limitations and may request assistance to participate in activities. ED did inform LPA that while staff provide escorts to R1 when available if they would like that to be apart of their care plan it would be an additional charge. Based on interviews, record review, and observations the above 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: 04/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025

LIC9099 (FAS) - (06/04)

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