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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200382
Report Date: 11/18/2021
Date Signed: 11/18/2021 01:55:49 PM

Document Has Been Signed on 11/18/2021 01:55 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 DIABLO LODGEFACILITY NUMBER:
079200382
ADMINISTRATOR:GRADY, WILLIAMFACILITY TYPE:
740
ADDRESS:950 DIABLO ROADTELEPHONE:
(925) 838-8300
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY: 128CENSUS: 90DATE:
11/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Bill Grady, Executive DirectorTIME COMPLETED:
02:05 PM
NARRATIVE
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On 11/18/2021 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Executive Director, Bill Grady.

While LPA was conducting a complaint investigation to deliver findings, the following deficiency was observed.

LPA observed S4 was not associated to the facility or other sister facilities.


The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.


Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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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Document Has Been Signed on 11/18/2021 01:55 PM - It Cannot Be Edited


Created By: Grace Luk On 11/18/2021 at 01:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE DIABLO LODGE
FACILITY NUMBER: 079200382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/24/2021
Section Cited
CCR
87355(e)(2)

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Criminal Record Clearance. Request a transfer of a criminal record clearance as specified in Section 87355(c) or...
This requirement is not met as evidence by:
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Executive Director has agreed to submit LIC9182 and a copy of photo ID for S4 to CCLD by POC date.
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Based on record review, licensee did not comply with the section cited above by not associated S4 to the facility which poses a potential health and safety risk to the persons 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2021


LIC809 (FAS) - (06/04)
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