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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200355
Report Date: 06/13/2025
Date Signed: 06/13/2025 10:32:31 AM

Substantiated


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
05/02/2025 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20250502163330
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: 71DATE:
06/13/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director, Lola BullockTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Licensee does not maintain the facility in good repair
INVESTIGATION FINDINGS:
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On 6/13/25 at 9:00 a.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver finding complaint investigation in regard to the allegation above. LPA met with Executive Director, Lola Bullock and explained the purpose of the visit.

During prior visit LPA interviewed S1, S2, ED and HWD and found that the southside elevator has been sporadically going down over the past few years and has been increasing in how often there are outages. ED states that they have been actively implementing solutions and has a work order out for repairs. Therefore the above allegation is Substantiated.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted and a copy of this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
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 2
Control Number 15-AS-20250502163330
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/11/2025
Section Cited
CCR
87303(a)
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(a) The facility shall be ...in good repair at all times...for the safety and well-being of residents...
This requirement is not met as evidence by:
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By POC facility agrees to submit documents for the work being done and notify CCLD of the completed repairs. LPA may conduct a case management once repairs are complete.
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Based on interviews the facility did not comply with the section cited above by the southside elevator going in and out of service over the last few years which poses a potential safety and personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2