079200382-11-1-2023-15-AS-YFLS-D22M4T-20240201081713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200382
Report Date: 11/01/2023
Date Signed: 11/01/2023 01:20:42 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
01/18/2023 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230118130142

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:	DATE:	11/01/2023
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Paula Arce, Life Enrichment Manager		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Personal Rights - Facility has inadequate record keeping of a resident while in care
Personal Rights - Staff did not address a resident change in medical condition
Personal Rights - Resident sustained injuries from multiple falls while in care
Personal Rights - Staff did not follow a resident's care plan while in care
Personal Rights - Staff did not properly report incidents involving a resident
Personal Rights - Staff did not provide adequate care and supervision to a resident

INVESTIGATION FINDINGS:

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On 11/1/2023 starting at 12:45 PM, Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to deliver findings for the above allegations. AGPA met with Life Enrichment Manager, Paula Arce and explained the purpose of the visit.

During course of the investigation, the Department conducted interviews with facility staff, witness and complainant. Documents including but not limited to: R1’s physician’s report, care plan, medication log, incident reports, hospice care notes, progress notes, and death certificate were obtained.

Allegation: Personal Rights - Facility has inadequate record keeping of a resident while in care

However, based on record review of R1’s progress notes and incident report, AGPA observed a history of notes by staff regarding R1’s fall and any changes in condition observed from March of 2022 to August of 2022.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

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 4

Control Number 15-AS-20230118130142

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: 11/01/2023

NARRATIVE

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Allegation: Personal Rights - Staff did not address a resident change in medical condition

However, based on interview with staff and W1, hospice was notified whenever staff observed a change in condition and nurse from hospice was requested by facility to assess resident. R1 was admitted to facility on January of 2022 and AGPA observed Personal Service Plan was updated, 3/4/22, and 8/22/2022 to address R1’s change in condition.

Allegation: Personal Rights - Resident sustained injuries from multiple falls while in care

Based on record review of incident report and progress notes, R1 had multiple unwitnessed falls on 1/28/22, 3/17/22, 8/12/22, and 8/14/22. However, no injuries were noted. R1 was admitted to ER on 3/17/22 and xray was completed, but no fractures were sustained from the fall.

Allegation: Personal Rights - Staff did not follow a resident's care plan while in care

Based on interview with W1, facility was following resident’s care plan and was in communication with hospice. W1 did not feel that there was any neglect by the facility according to the records from the nurses in charge during the time R1 was under hospice care.

Allegation: Personal Rights - Staff did not properly report incidents involving a resident

Based on record review, responsible party was notified of R1’s multiple falls that occurred on 1/28/22, 3/17/22, 8/12/22, and 8/14/22.

Allegation: Personal Rights - Staff did not provide adequate care and supervision to a resident

Based on record review, facility addressed the concern with R1’s responsible party regarding R1’s multiple falls. A care conference was held on 8/15/2022 where facility recommended a 1:1 companion for R1 due to increased agitation. However, R1’s responsible party refused. R1 was being checked by staff every 2 hours.

Although the allegations may have happened or are valid, there are 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 report provided to Life Enrichment Manager.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4

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
01/18/2023 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230118130142

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:	DATE:	11/01/2023
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Paula Arce, Life Enrichment Manager		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Personal Rights - Questionable Death

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20230118130142

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: 11/01/2023

NARRATIVE

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Allegation: Personal Rights - Questionable Death

The Department obtained a copy of R1’s death certificate where it indicates that the cause of death was due to chronic congestive heart failure and coronary artery disease. R1 was admitted to hospice on July 25, 2022 and was diagnosed with heart failure and not related due to neglect of the facility.

This agency has investigated the complaint alleging questionable death. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted and a copy of this report provided to Life Enrichment Manager.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4