079200382-10-19-2023-15-AS-AGOZ-CWRVYR-20231019165135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200382
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:51:43 PM

Document Has Been Signed on 10/19/2023 04:51 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 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: 99	DATE:	10/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Rachael Davis, Executive Director		TIME COMPLETED:	05:00 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	Licensing Program Analysts (LPA) A. Gomez and Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to conduct a 1-Year Annual Required visit on this date starting at 10:40AM. Upon arrival, LPA and AGPA met with Executive Director, Rachael Davis. The facility's fire clearance was approved for all may be non-ambulatory of which 8 may be bedridden. LPA and AGPA toured the facility inside and out with Executive Director including but not limited to facility hallways, activity room, dining room, kitchen, resident rooms and medicine room. Indoor and outdoor passageways were kept free of obstruction. There are no bodies of water observed. Hot water temperature in random resident's bedroom was maintained at 113.6 degrees F. In another Residents room, hot water temperature was maintained at 114.1 degrees F. A comfortable room temperature was maintained at 73 degrees F in the hallway. Facility was equipped with a minimum of one week supply of non-perishable and 2-day supply of perishable food. Medication carts were observed locked. LPA's reviewed a sample of medication. Fire extinguisher was last serviced on 09/12/2023. Smoke detectors and sprinklers are interconnected and observed throughout facility. LPA and AGPA reviewed 5 staff records and 5 of 5 are associated and have current first-aid training. LPA reviewed 5 residents records. The following deficiencies were observed At 12:17PM LPA's observed Miralax in R4's apartment. At 12:35PM LPA's observed TUMS in R5's apartment. REPORT CONTINUES ON 809C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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

LIC809 (FAS) - (06/04)

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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 DIABLO LODGE	FACILITY NUMBER: 079200382
	VISIT DATE: 10/19/2023

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 11/02/2023:
LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Executive Director. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/19/2023 04:51 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BROOKDALE DIABLO LODGE	FACILITY NUMBER: 079200382
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

87465(h)(2) INCIDENTAL MEDICAL AND DENTAL CARE (h)The following requirements shall apply to medications which are centrally stored: (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by R4 having Miralax in apartment and R5 having TUMS in apartment. Physician's report for R4 and R5 indicates that both residents are not able to store PRN medications which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/20/2023
	Plan of Correction
1 2 3 4	By POC date Administrator agrees to remove all PNR medications from R4 & R5 apartment and submit self-certification letter to CCLD. In addition Administrator will review regulation and audit all clients records and apartments to be in compliance with the section cited above and submit self certification to CCLD by 11/02/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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