079200382-11-18-2021-15-AS-HHUL-CF2TK9-20220603144735

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200382
Report Date: 11/18/2021
Date Signed: 11/18/2021 01:52:52 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/22/2020 and conducted by Evaluator Grace Luk

COMPLAINT CONTROL NUMBER: 15-AS-20201022092629

FACILITY NAME:	BROOKDALE DIABLO LODGE		FACILITY NUMBER:	079200382
ADMINISTRATOR:	GRADY, WILLIAM		FACILITY TYPE:	740
ADDRESS:	950 DIABLO ROAD		TELEPHONE:	(925) 838-8300
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94526
CAPACITY:	128	CENSUS: 90	DATE:	11/18/2021
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Bill Grady, Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility is not kept clean

INVESTIGATION FINDINGS:

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On 11/18/2021 at 8:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegation above. LPA met with Executive Director, Bill Grady.

During the investigation, LPA interviewed staff and complainant. LPA obtained and reviewed R1's file including physician's report, care plan, and care notes.

LPA conducted a virtual tour of the facility and R1's room on 10/30/2020. LPA observed R1's room had stains on the carpet and bathroom had spots of brown/yellowish smeared on the counter top. Interview with staff revealed that no one went into R1's room when 911 was activated and R1 was taken to the hospital. Staff stated that R1's room is normally cleaned on a daily basis and weekly by housekeeping.
(Continue on LIC9099...)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
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.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 15-AS-20201022092629

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE DIABLO LODGE	FACILITY NUMBER: 079200382
	VISIT DATE: 11/18/2021

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/22/2020 and conducted by Evaluator Grace Luk

COMPLAINT CONTROL NUMBER: 15-AS-20201022092629

FACILITY NAME:	BROOKDALE DIABLO LODGE		FACILITY NUMBER:	079200382
ADMINISTRATOR:	GRADY, WILLIAM		FACILITY TYPE:	740
ADDRESS:	950 DIABLO ROAD		TELEPHONE:	(925) 838-8300
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94526
CAPACITY:	128	CENSUS: 90	DATE:	11/18/2021
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Bill Grady, Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff did not assist resident with hygiene needs
Facility is malodorous

INVESTIGATION FINDINGS:

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On 11/18/2021 at 8:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegations above. LPA met with Executive Director, Bill Grady.

During the investigation, LPA interviewed staff and complainant. LPA obtained and reviewed R1's file including physician's report, care plan, care notes, and emergency information.

R1's care plan reveal that R1's shower days are Monday, Wednesday, Friday, and Saturday. R1 needed assistance with toileting and changing diapers as needed. Interview with staff reveal that R1 is check every 2-3 hours for incontinence care. Staff stated that R1 would be cleaned and sometimes showered after an accident on top of the regular showers scheduled for R1. Staff stated that R1 would refuse care sometimes and staff would go back at a later time to provide care for R1. (Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
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.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 15-AS-20201022092629

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE DIABLO LODGE	FACILITY NUMBER: 079200382
	VISIT DATE: 11/18/2021

NARRATIVE

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Due to the pandemic, LPA only conducted a virtual tour of the facility on 10/30/2020 and was not able to observe the smell of R1's room. Interview with the staff revealed that R1 had a pet cat and cat food has a smell. However, staff stated that R1's room did not have a strong odor.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20201022092629

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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 11/19/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidence by:	1 2 3 4 5 6 7	LPA observed a new resident occupying R1's room and observed the room to be cleaned without odor. No POC needed. Deficiency cleared during inspection.
	8 9 10 11 12 13 14	Based on investigation, licensee did not comply with the section cited above by having R1's room uncleaned which poses a potential health and safety risk to the persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
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

LIC9099 (FAS) - (06/04)

Page: 5 of 5