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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200355
Report Date: 08/09/2024
Date Signed: 08/09/2024 03:33:58 PM


Document Has Been Signed on 08/09/2024 03:33 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
OAKLAND ASC, 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: 75DATE:
08/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Niare Feaster, Executive DirectorTIME COMPLETED:
03:50 PM
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On 08/09/2024 at 1:50 p.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit due to receiving an Unusual Incident Report (UIR) of a resident having attempted suicide. LPA met with Niare Feaster, Executive Director and explained the purpose of the visit.

R1 was admitted to the facility on 9/29/23. Physician's Report dated 6/07/24 indicates that R1 was independent and could leave the facility unassisted. Report indicates that R1 was not at risk of accessing personal grooming supplies. The report also documented that R1 did not have any suicidal ideations.

ED stated that R1 had 2 cuts about 1 inch each and that the cuts did not require stiches. Resident is still on a 5150 hold and has not returned to the facility. R1 refused to be transported to the hospital and received first aid from the EMT's. RP was notified of incident and came to the facility to speak to ED and at that time R1 admitted that the cuts were self inficted and that they planned on doing it again. ED notified law enforcement and R1 was 5150 when EMT's returned. R1 is to be reassessed before returning to the facility. RP and ED will determine the best course of action and develop a new care plan as needed.

Health and Wellness Director filed an UIR and informed LPA via phone of the incident.

LPA toured R1's room with S1 and observed it to be within regulation standards.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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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