015601255-7-26-2023-15-AS-LFII-CU4VSZ-20230726164223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601255
Report Date: 07/26/2023
Date Signed: 07/26/2023 04:42:28 PM

Document Has Been Signed on 07/26/2023 04:42 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	BROOKDALE NORTH FREMONT		FACILITY NUMBER:	015601255
ADMINISTRATOR:	ANGIE R. CHANEY		FACILITY TYPE:	740
ADDRESS:	38035 MARTHA AVE		TELEPHONE:	(510) 797-4011
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	40	CENSUS: 25	DATE:	07/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:57 PM
MET WITH:	ANGIE R. CHANEY, Administrator		TIME COMPLETED:	04:50 PM

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	On 7/26/2023 starting at 12:57 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with ANGIE R. CHANEY, Administrator (ADM) and explained the purpose of the visit. Administrators certificate (6058954740) is valid and expires on 9/6/2023. The facility’s fire clearance was approved for all forty (40) residents, which thirty (30) may be non- ambulatory residents and approved for ten (10) bedridden residents. Starting at 1:20 PM, LPA toured facility with ADM including but not limited to twenty (20) bedrooms, twenty-two (22) bathrooms, kitchen, common area and backyard. The facility consists of 20 total bedrooms which 4 bedrooms are private, and 21 rooms are shared. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents'. The hot water temperature in residents’ common area bathroom was measured at 105.3 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day of perishable foods. Sharps and toxins were locked and inaccessible to residents'. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was observed last serviced on 5/4/2023. First aid kit was observed to be complete. Continue on Lic809-C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: BROOKDALE NORTH FREMONT	FACILITY NUMBER: 015601255
	VISIT DATE: 07/26/2023

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

Continued from Lic809

Starting At 2:04 PM, LPA reviewed 10 of 10 staff records. At 3:38 PM, LPA reviewed 10 of 10 residents' record which are current. At 4:32 PM, LPA reviewed a sample of 10 of 10 residents' medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 8/2/2023:

· LIC 308 Designation of Administrative Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 Pages)
· Liability Insurance

No deficiencies cited during visit.

Exit interview conducted with ADM, and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2