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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200382
Report Date: 01/19/2023
Date Signed: 01/19/2023 05:18:23 PM


Document Has Been Signed on 01/19/2023 05:18 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: 98DATE:
01/19/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Rachael Davis, Executive DirectorTIME COMPLETED:
05:30 PM
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On 1/19/2023 starting at 3:30 PM, Licensing Program Analysts (LPAs) L. Francisco and P. Watson conducted a Health & Safety inspection as a result of a Priority 1 complaint. LPAs met with Executive Director, Rachael Davis and explained the purpose of the visit.

LPAs toured facility including but not limited to the random apartments, bathrooms, common areas, and kitchen. A sample of hot water temperature were maintained at 114, 115.1, and 113.8 degrees F in random residents apartments. LPAs observed an adequate one week of non-perishable and 2-day of perishable food supply. Resident's medications were kept locked in the medication cart. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be fullt charged and last serviced on 8/10/2022. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING HEALTH & SAFETY INSPECTION
  • At 3:30 PM, LPAs observed unlocked cleaning supplies, bug spray, and bleach inside kitchen cabinet and bathroom cabinets in R1's apartment
  • At 3:36 PM, LPAs observed unlocked gardening tools, oxyclean, and comet.


The following deficiency was observed (see LICd 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided to Executive Director.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/19/2023 05:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
01/20/2023
Section Cited

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87309(a) STORAGE SPACE
Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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By POC date, Administrator agrees to conduct room checks and submit a self-certification letter that cleaning supplies have been removed and locked away to CCLD
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Based on observation, Licensee did not comply with the regulations cited above. LPAs observed unlocked cleaning supplies and gardening tools in R2's apartment; and cleaning supplies in R1's apartment which poses an immediate health and safety risk to 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
LIC809 (FAS) - (06/04)
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