015601255-1-30-2025-15-AS-BFOG-DDL4PF-20250204181641

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601255
Report Date: 01/30/2025
Date Signed: 01/30/2025 04:52:38 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/09/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20211209125343

FACILITY NAME:	BROOKDALE NORTH FREMONT		FACILITY NUMBER:	015601255
ADMINISTRATOR:	EBONY (LADY) REED		FACILITY TYPE:	740
ADDRESS:	38035 MARTHA AVE		TELEPHONE:	(510) 797-4011
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	40	CENSUS: 29	DATE:	01/30/2025
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Simone Hall/Executive Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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-Staff yelled at residents.
-Staff handled residents in a rough manner.
-Staff were mismanaging resident's medication.
-Resident's diapering needs were not being met.
-Resident's hygiene needs were not being met.
-Facility is short staffed.

INVESTIGATION FINDINGS:

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On this day, 1/30/25, at 2:20 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations and close the complaint. LPA met with Executive Director (ED) Simone Hall, and informed the purpose of visit.

During the course of investigation, LPA obtained copies staff schedule, resident roster and staff medication training records, and conducted file review including Medication Administration Records (MAR). LPA also obtained copies of residents' following documents: Identification andf Emergency Contact Information; LIC602A Physician's Report; Appraisal; lists of medications; Medication Administration Records; LIC622 Centrally Stored Medication and Destruction Record. LPA interviewed caregivers and a med-tech (S3, S4, S5), previous ED, witnesses (R2's personal companion and Home Health staff), resident (R1) and resident's family member (FM) on 12/24/21. LPA tried to reach to staff (S1 and S2) on 1/28/25.

....continued on 9099C (page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

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 5

Control Number 15-AS-20211209125343

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 NORTH FREMONT	FACILITY NUMBER: 015601255
	VISIT DATE: 01/30/2025

NARRATIVE

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Page 2

Allegation: Staff (S1) yelled at residents.
Reporting party (RP) stated that S1 yells at residents. One out of the 3 staff stated observing S1's voice escalates while the other 2 staff stated not observing S1 yelled at any residents. These 3 staff stated some of the residents are hard on hearing so they have to speak loud at times. One out the 2 witnesses stated observing S1 raised voice to other residents while the other witness and FM stated not observing staff yelled at residents. Resident (R1) stated the staff do not yell at him. LPA was unable to obtain information from S1. Therefore, the allegation in unsubstantiated.

Allegation: Staff handled residents in a rough manner.
RP stated S1 was rough with administering medications and shoved medication in the mouth of residents.
All 3 staff stated not observing S1 being rough and shoving medications in the residents' mouth. One of the witnesses stated observing S1 being rough to resident R2. Due to medical diagnosis, LPA was unable to obtain information from R2. LPA was also unable to obtain information from S1. Therefore, the allegation in unsubstantiated.

Allegation: Staff were mismanaging resident's medication.
RP stated that S1 administers Melatonin to R2 before or during dinner time when it should be given at bedtime. RP further stated by the time RP arrives to the facility at 6:00 pm, R2 was already sleepy. One of the 3 staff interviewed stated observing S1 administers medications at 7:00 pm but this staff does not know the medications being given. The other staff stated she knew R2 has Melatonin medication but has not observed S1 administer it in the afternoon. Review of MAR showed the Melatonin is administered at night. R2's personal companion stated not observing the med-tech give Melatonin to R2 before 8:00 pm. Due to medical diagnosis, LPA was unable to obtain information from R2. LPA was unable to obtain information from S1. Therefore, the allegation in unsubstantiated.

.....continued on 9099C (page 3)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20211209125343

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 NORTH FREMONT	FACILITY NUMBER: 015601255
	VISIT DATE: 01/30/2025

NARRATIVE

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Page 3

Allegation: Resident's diapering needs were not being met.
RP stated the residents were walking around with heavy diapers. The 2 care staff stated they changed the residents' diapers at least 2 times and as needed during their shift. The 2 witnesses (R2's personal companion and Home Health staff) and FM stated not observing residents not changed nor smelly. FM stated not observing R2's diaper's wet. LPA did not observed any residents in heavy diapers nor smelly. Resident (R1) stated the staff assist when he needed help. LPA was unable to obtain information from R2 due to medical diagnosis. LPA was also unable to obtain information from the other care staff (S2). Therefore, the allegation in unsubstantiated.

Allegation: Resident's hygiene needs were not being met.
RP stated observing staff (S2) not wiping when changing residents and noticed residents were starting to smell. FM stated he visited almost everyday and had not observed R2 smelly and that R2 was always clean. The two witnesses stated not observing the residents smelly. Resident (R1) stated the staff assist when he needed help. LPA was unable to obtain information from the other care staff (S2). Therefore, the allegation in unsubstantiated.

Allegation: Facility is short staffed.
RP stated there were only 2 to 4 caregivers for 35 residents. One of the caregivers interviewed stated there were time when work was overwhelming but still able to provide the care needs of the residents. The other caregiver stated that with the staffing ratio, work was manageable. The med-tech stated facility was short-staffed when staff call-in-sick, so they work extended hours. If they find somebody to cover, it's covered, otherwise they have to adjust their schedule and work overtime. Review of LIC500 Personnel Report showed staff schedules varies which confirmed the med-tech's statement. During LPA's initial visit, the facility's census was 26 residents and LPA observed at least 3 staff on the floor and a staff from the temp agency was also present. R2 stated when he needed help, the staff assisted him.

Based on all information gathered, all 6 allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/09/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20211209125343

FACILITY NAME:	BROOKDALE NORTH FREMONT		FACILITY NUMBER:	015601255
ADMINISTRATOR:	EBONY (LADY) REED		FACILITY TYPE:	740
ADDRESS:	38035 MARTHA AVE		TELEPHONE:	(510) 797-4011
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	40	CENSUS: 29	DATE:	01/30/2025
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Simone Hall/Executive Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff administering medications does not have medications training,

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20211209125343

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 NORTH FREMONT	FACILITY NUMBER: 015601255
	VISIT DATE: 01/30/2025

NARRATIVE

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Page 2

The previous ED stated S2 is not a med-tech and does not administer medications. The 2 staff (S3 and S4) stated not observing S2 administered medications. S5 stated she's a med-tech and has completed the required medication training which LPA confirmed S5 is a med-tech upon review of LIC500 Personnel Report. Review of training records confirmed S5 has the required medication training. The resident's personal companion also stated not observing S2 administered medications.

Based on information obtained, the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 5