079200382-7-10-2023-15-AS-KHOS-CU3PXH-20230725114219

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200382
Report Date: 07/10/2023
Date Signed: 07/10/2023 05:00:31 PM

Unsubstantiated

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
07/03/2023 and conducted by Evaluator James Sampair

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230703130036

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: 104	DATE:	07/10/2023
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Executive Director Rachel Davis & Health & Wellness Director Jinder Kaur		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility elevator does not meet backup power requirements.
Staff did not follow emergency procedures during a power outage.
Staff not trained on emergency procedures during a power outage.

INVESTIGATION FINDINGS:

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On 07/10/2023 at 9:35 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to investigate the allegations above. Upon arrival, LPA stated purpose of the visit to Executive Director (ED) Rachel Davis and Health & Wellness Director (HWD) Jinder Kaur.

During the LPA's investigation, the ED and HWD provided the requested records and spoke in detail with LPA about the backup requirements for their facility's elevators, the facility's emergency procedures, and the staff training on those procedures during a power outage. The LPA reviewed facility records that included the Emergency Manual, monthly safety drill records, and Unusual incident reports, and interviewed 1 resident and 2 staff members about R1 being trapped in an elevator during a power outage on 07/01/2023.

(Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230703130036

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 DIABLO LODGE	FACILITY NUMBER: 079200382
	VISIT DATE: 07/10/2023

NARRATIVE

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(...Continued from LIC9099)

Facility elevator does not meet backup power requirements.
Based on a review of regulations, facility records, and interview of ED the facility elevator does meet the existing backup power requirements.

Staff did not follow emergency procedures during a power outage.
Based on interviews of R1, ED, HWD, S1, S3, and facility records, staff did follow emergency procedures during the power outage of 07/01/2023.

Staff not trained on emergency procedures during a power outage.
Based on interviews of ED, HWD, S1, S3, and facility records, staff was trained extensively on emergency procedures.

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

Exit interview conducted and a copy of this report emailed to ED.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

LIC9099 (FAS) - (06/04)

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