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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601255
Report Date: 02/11/2025
Date Signed: 02/11/2025 03:36:31 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
02/07/2025 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250207104901
FACILITY NAME:BROOKDALE NORTH FREMONTFACILITY NUMBER:
015601255
ADMINISTRATOR:HALL, SIMONE SFACILITY TYPE:
740
ADDRESS:38035 MARTHA AVETELEPHONE:
(510) 797-4011
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:40CENSUS: 30DATE:
02/11/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Executive Director Simone HallTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
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9
Staff did not provide adequate supervision, resulting in a resident sustaining multiple falls and injuries.
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
8
9
10
11
12
13
On February 11, 2025 at 11:30 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced at the facility for a visit to investigate the allegation above. Upon entry into the facility, the LPA identified himself and stated the purpose of the visit to Executive Director (ED) Simone Hall.
The complaint alleges that staff did not provide adequate supervision, resulting in Resident R1 sustaining multiple falls and injuries.

The LPA interviewed the ED, Witness W1, a nurse with the California Department of Public Health, and W2, a nurse with Pathways Home Health and Hospice. The LPA reviewed R1's file, hospice file, hospice care plan, and Physician’s Report. The data collected does not confirm the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
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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