Brookdale Danville
RCFE · Memory Care
A Residential Care Facility for the Elderly (RCFE) is a non-medical residential care home licensed by California CDSS under Health & Safety Code §1560. Residents receive help with daily living activities such as bathing, dressing, and medication management. An RCFE with a Memory Care designation is additionally required by California Title 22 (§87705 and §87706) to provide specialized staff training in dementia care, individualized care plans for residents with cognitive impairment, and appropriate supervision protocols — requirements that go beyond a standard RCFE license.
400 W el Pintado Rd · Danville, 94506
Quick facts
Quality snapshot
Updated April 25, 2026Compared to 25 California RCFE memory care facilities of similar size, over the last 36 months.
Source: California Department of Social Services, Community Care Licensing Division. View raw inspection records →
Quality grade· click to show how this was calculated
Severity42thWeighted citations per bed
Repeats100thRepeat deficiencies as share of total
Frequency50thDeficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Quality grade· click to show how this was calculated
Weighted citations per bed
Repeat deficiencies as share of total
Deficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Brookdale Danville scores B−. Better than 64% of comparable California RESIDENTIAL CARE ELDERLY facilities. Severity: 42th percentile. Repeats: top 0%. Frequency: 50th percentile.
Each metric is converted to a 0–100 percentile within the peer set (higher = better). The composite grade averages all four. Peer set: CA / rcfe_memory_care / medium beds (25 facilities).
Citation severity over time
↓ improvingWeighted severity score per month · 24 months
Weighted score (24mo)
21
Last citation
Mar 26
Finding distribution
13 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility
California Title 22 requirements for this facility, with the specific regulation and a suggested question for each.Rules this facility has been cited for are shown first.
What dementia-care training must staff complete?Cited May 202422 CCR §87705 / HSC §1569.625
Because this facility markets dementia or Alzheimer's care, state law mandates higher training standards:
- 12 hours initial dementia training — 6 hours before a staff member works independently with residents, 6 more within the first 4 weeks.
- 8 hours annual dementia in-service — required every year thereafter.
- Administrator CE — the administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle.
Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
Ask on tour: Ask how dementia training records are kept — families may request documentation.
What must this facility report to the state — and how fast?Cited May 202422 CCR §87211 / WIC §15630
- ImmediateElopement, fire, epidemic outbreak, or poisoningImmediately
- 2 hoursAbuse with serious bodily injury2-hour phone report + 2-hour written report — to the California Department of Social Services (CDSS), Adult Protective Services, and law enforcement
- 24 hrsAbuse without serious bodily injuryWithin 24 hours
- Next dayDeath of a residentPhone by next working day; written within 7 days
- Next dayInjury requiring medical treatment beyond first aidPhone by next working day; written within 7 days
- WrittenBankruptcy, foreclosure, eviction, or utility shutoff noticeWritten notice to CDSS and residents — $100/day penalty (max $2,000) for failure
Your enforcement lever:Incidents that aren't reported on time are themselves a separate violation. If you believe a reportable event wasn't filed, you can submit a complaint directly to the California Department of Social Services (CDSS).
How many staff must be on duty overnight?22 CCR §87415
Based on 42 licensed beds:
One awake caregiver must be on duty, plus one additional caregiver on call who can respond within 10 minutes.
Violation pattern to watch for:A facility that documents a staff member as "on call" but with that person physically off-site — when the law requires on-premises presence — is in violation of this section.
Ask on tour: Ask the facility to walk you through their overnight staffing plan and confirm whether on-call staff are on premises or off-site.
What health conditions can this facility legally accept or refuse?22 CCR §87612–87615
Restricted — allowed with physician order + care plan
- Supplemental oxygen
- Insulin and injectable medications
- Indwelling or intermittent catheters
- Colostomy / ileostomy
- Stage 1 and Stage 2 pressure injuries
- Wound care (non-complex)
- Incontinence
- Contractures
Prohibited — facility must refuse or discharge
- Stage 3 or Stage 4 pressure injuries
- Feeding tubes (PEG, NG, or J-tube)
- Tracheostomies
- Active MRSA or communicable infections requiring isolation
- 24-hour skilled nursing needs
- Total ADL dependence with inability to communicate needs
A hospice waiver (HSC §1569.73) can allow continued care for residents on hospice who would otherwise fall into a prohibited category.
Ask on tour: Ask whether your loved one's specific care needs are restricted or prohibited, and what the facility's process is if needs change after admission.
How does CDSS enforce these rules?22 CCR §87755–87777 / HSC §1569.58
- 1Notice of DeficiencyWritten citation with a correction deadline. Facility must submit a Plan of Correction.
- 2Civil PenaltyStarts at $50/day for non-serious; $150/day for serious deficiencies — immediately, with no grace period. Repeats escalate to $150 first day + $50/day, then $1,000 first day + $100/day.
- 3Suspension of AdmissionsFacility cannot accept new residents until violations are corrected.
- 4Temporary Suspension or RevocationEmergency suspension for imminent danger; full revocation after administrative hearing.
- 5Exclusion OrderAdministrator and operator can be barred from all CDSS-licensed facilities — not just this one.
See how these rules have been applied to this specific facility:
View state inspection record and citationsState records
California Dept. of Social Services · Community Care Licensing- License number
- 075601257
- License type
- RESIDENTIAL CARE ELDERLY
- License status
- LICENSED
- License expires
- Not yet indexed
- Licensed beds
- 42
- Operator
- Summerville at Barrington Court; Emeritus Corp
Inspections & citations
13
reports on file
13
total deficiencies
1
Type A (actual harm)
2
dementia-care citations
Other visitApril 15, 2026No deficiencies
Plain-language summary
A routine annual inspection was conducted on April 15, 2026, and no violations were found. The facility's living areas, bathrooms, kitchen, and safety equipment (fire extinguishers, first aid kits, emergency plans) were reviewed and met requirements, with adequate lighting, appropriate water temperature, grab bars in bathrooms, and medications stored securely. The inspector requested updated documentation to be submitted by April 20, 2026, and recommended that all required staff complete first aid and CPR training.
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On 4/15/2026 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Business Office Director, Kristy Andrews and explained the purpose of the visit. The facility’s fire clearance was approved for all may be non-ambulatory and 15 bedridden. LPA toured the facility with Maintenance including but not limited to residents apartments, bathrooms, activity room, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom measured between 105-120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Fire extinguisher was last serviced on 2/2/2026. First aid kit was observed to be complete. Emergency disaster drill completed 2/24/2026. Emergency Disaster plan reviewed 3/9/2026 LPA reviewed 5 residents records. LPA reviewed 5 staff records LPA advised facility to complete first aid training/ CPR for all required staff through such agencies as the American Red Cross and all staff were associated to the facility. Updated copies of the following documents were requested for facility file and are to be mailed to CCL by 4/20/2026: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
Other visitMarch 19, 2026Type B3 deficiencies
Plain-language summary
On March 19, 2026, inspectors conducted a case management visit and found dirty resident rooms and bathrooms with fecal matter on a toilet, dried blood on a wall, and damaged furniture with soiled cushions in common areas. The facility was also cited for insufficient staffing, with only three caregivers present when five of twenty-three residents needed two-person assistance. The facility stated it was actively hiring additional maintenance, housekeeping, and care staff to address these issues.
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On 3/19/2026 Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit. LPA met with Resident Care Coordinator, Christine Montemayor and explained the purpose of the visit. Executive Director, Cecily Palma was notified and arrived at approximately 11:20am On 10/3/2025 LPA A Gomez conducted a case management vist as a result of a self reported incident.During the visit on 10/3/2025 LPA observed residents room floors dirty and bathrooms unclean with dry fecal matter on the toilet in room 11. Operations Specialist stated that they are actively looking for a new maintenance and house keeping. LPA also observed that were not enough caregivers on shift. On 10/3/2025 there were 3 caregivers available, five out of twenty-three residents require a two person assist, facility states they were also hiring more care staff. LPA also observed facility common area/ activities area furniture (ie chairs and couches) in disrepair and damaged. LPA stated that they would return at a later date to cite for deficiencies observed and will now cite on todays date. LPA also observed on todays date dried blood on wall in room 18 and that common area chairs/sofas are in disrepair by being peeled/split on the cushions as well as the arm rests being soiled. 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. Appeal Rights and a copy of this report provided.
Regulation
(a) A licensee shall ensure that infection control...as follows:(2) Environmental cleaning...at a minimum, as follows:(A)Surfaces ... visibly soiled with...potentially infectious material. This requirement was not met as evidence by:
Inspector finding
Based on LPAs observations the facility did not disinfect the visibly soiled surface in room 11. LPA observed that the surface had dried feces, dried blood on wall next to bed, and floors were unsanitary which posed a potential health and personal rights risk to residents in care.
Regulation
(a) Facility personnel shall at all times be sufficient in numbers...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the pr…
Inspector finding
Based on LPAs observations and record review facility care staff numbers is not suffient to meet the residents needs because on 10/3/2025 5 out of 23 residents require a two person assist and three caregivers and one medtech were on shift which posed a potential personal rights risk to residents in care.
Regulation
(d) The following...shall apply to all facilities:(2) The premises shall be maintained in a state of good repair... This requirment is not met as evidence by:
Inspector finding
Based on observation the facility did not maintain the furniture in a state of good repair by activities area sofas ripping at seams and exposing nails that pointed up which posed a potential safety and personal rights risk to residents in care.
Other visitOctober 21, 2025No deficiencies
Plain-language summary
On October 21, 2025, inspectors visited the facility to follow up on a previous complaint and requested documents. The facility's legal team advised them not to release corrective action records to the licensing agency, which violated state requirements; the inspector requested the facility provide written explanation of this denial. The facility was cited for failing to provide requested documents to the licensing authority.
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On 10/21/2025 at 12:00PM, Licensing Program Analyst (LPA) A Gomez conducted a case management while at the facility for complaint 15-AS-20250612143154. LPA met with Operations Specialist, Dimple Kamdar and explained the reason for the visit. During visit, LPA returned to follow up on documents that were requested. During the visit LPA was informed by Operations Specialist, Dimple Kamdar that they were advised by their legal team that corrective actions (write ups) will not be released to CCLD. LPA advised Operations Specialist, Dimple Kamdar of the regulation and requested the denial with reasoning in writing via certified mail. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: Facility not providing requested documents as allowed; Inspection Authority of the Licensing Agency 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. Appeal Rights and a copy of this report provided.
Other visitOctober 3, 2025No deficiencies
Plain-language summary
On October 3, 2025, state inspectors arrived unannounced to investigate a self-reported incident of alleged abuse and inadequate care by staff members; the facility's executive director was terminated for failing to escalate these allegations. Inspectors found dirty resident rooms and bathrooms with fecal matter on a toilet, insufficient caregivers on duty (only 3 staff for 23 residents when 5 require two-person assistance), and damaged furniture in common areas; the facility stated it is hiring additional housekeeping and care staff. The inspector indicated violations will be cited on a follow-up visit.
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On 10/3/2025 at 9:00AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit in regards to a self report incident received on 9/24/2025. LPA met with Operations Specialist, Dimple Kamdar and explained the reason for the visit. Based on the report received on 9/24/2025, it is alleged that S1 and S2 are abusing residents. It is also alleged that S2 and S3 are not providing adequate care to residents. Executive Director (ED) Theresa Truong was also suspended for failure to escalate the alleged incidents of abuse. ED has since been terminated. During visit, LPA requested copies of S1-S3 personnel record including but not limited to any and all disciplinary actions/ write ups, most recent training records, job positions held, schedules for all of 2024 and 2025; Records of all staff for 2024-2025, staff schedules, all write ups related to care; Transcripts of the allegations of abuse made by an anonymous caller, ED full termination record. During the visit LPA observed residents room floors dirty and bathrooms unclean with dry fecal matter on the toilet in room 11. Operations Specialist states that they are actively looking for a new maintenance and house keeping. LPA also observed that there are not enough caregivers on shift. On 10/3/2025 there were 3 caregivers available, five out of twenty-three residents require a two person assist, facility states they are also hiring more care staff. LPA also observed facility common area/ activities area furniture (ie chairs and couches) in disrepair and damaged. LPA will cite for the deficiencies observed today on return visit. Exit interview conducted. A copy of this report provided.
Other visitApril 4, 2025No deficiencies
Plain-language summary
This was the facility's annual routine inspection on April 10, 2024, which found no violations. The inspector checked the building's safety features including lighting, temperature, bathrooms with grab bars, food and medication storage, fire equipment, and staff records, and confirmed everything met requirements.
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On 4/10/2024 at 8:45 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Teresa Truong and explained the purpose of the visit. The facility’s fire clearance was approved for all may be non-ambulatory and 15 bedridden. LPA toured the facility with Executive Director including but not limited to residents apartments, bathrooms, activity room, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 108.9, 111.9, 112.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Fire extinguisher was last serviced on 1/09/2025. First aid kit was observed to be complete. Emergency disaster drill completed 3/25/2025. Emergency Disaster plan reviewed 4/10/2024 At 9:30AM, LPA reviewed 6 residents records. At 10:30AM, LPA reviewed 5 staff records and required staff have current first aid training and all staff are associated to the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
InspectionApril 4, 2025No deficiencies
Plain-language summary
On March 22, 2025, a staff member found a resident on the floor and reported seeing another staff member stepping on the resident; however, the staff member who reported it later said they may have misinterpreted what they saw and reported it out of caution. The resident, who has dementia and cannot remember the incident, had no visible injuries and was observed yelling out randomly during the inspector's visit. The inspection found no violations.
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On 4/4/2025 at 12:30 PM LPA A Gomez arrived to conduct a case management as a result of an unusual incident report received on 3/27/2025. LPA met with Executive Director (ED), Teresa Truong and explained the purpose of the visit. On Saturday, 3/22/2025, R1 was found on the floor of their room by S1 and S2. S2 went for help and when they returned they reported seeing S1 stepping on R1 and R1 yelling out. There were no other witnesses. LPA reviewed the Physicians report and Needs and services for R1. R1 is diagnosed with dementia. R1 was also observed randomly yelling out in the presence of LPA seemingly without cause. R1 is unable to recall the event and has no visible injuries. ED states that they spoke with S2 who reported the incident and S2 states that they may have just seen the incident at a wrong angle but reported just to be safe. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
Other visitJune 14, 2024No deficiencies
Inspector: Alona Gomez
Plain-language summary
On May 23, 2024, a resident with a cane attacked two other residents in their room, injuring both who were taken to the hospital; staff separated them and called 911 and police. The attacking resident was placed on one-to-one supervision and later moved to another facility when staff determined the facility could not meet their needs, while the two injured residents recovered and returned to baseline. The facility provided additional dementia and aggression training to staff, and no violations were cited.
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On 6/14/2024 at 2:00 PM LPA A Gomez arrived to conduct a case management as a result of an unusual incident report received on 5/24/2024. LPA met with Executive Director, Teresa Truong and explained the purpose of the visit. On Thursday, 5/23/2024, at 9:50 pm, staff heard screaming coming from room #9; staff ran to the room. and saw the R1 had a cane in hand attempting to hit R2 and R3 as they were on the floor. Staff were able to escort R1 out of the room, 911 was called for the R2 and R3, and they were sent to the hospital. Police were notified as well as all responsible parties. LPA reviewed the Physicians report and Needs and services for R1. Prior to the incident R1 did not require a 1:1 and did not have a record of violent tendencies. ED states that after the incident R1 was provided a 1:1 and assessed to see if there was a higher level of care. R1 did have additional outburst with staff after incident and family agreed that the facility was not appropriate for R1's care needs. R1 no longer resides at the facility. R2 and R3 have returned from the hospital and are back to baseline. The facility continues to monitor them for any changes. Staff were additionally trained on care for residents with dementia and aggressive behavior. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
ComplaintMay 14, 2024· MixedType B4 deficiencies
Inspector: Jill Clancy-Czuleger
Plain-language summary
An investigation of complaints found that the facility did not have enough staff and failed to report incidents that occurred—staff were unaware of reporting requirements after a key person left. However, investigators found no problems with how meals were served, special dietary needs were handled, or how medications were given to residents. The facility was cited for the staffing and reporting violations.
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...Continued from 9099 On the allegation facility do not ensure adequate care and supervision is provided to residents in care. Based on record review and interviews the facility did not have enough staff. S1 stated that at the time of the complaint there was a shortage in staffing. On the allegation facility staff do not ensure reporting requirements are followed. Based on record review and interviews the facility was not reporting incidents that were happening. S2 stated that S3 was responsible for reporting but she left the facility and other staff were unaware of the reporting process and reporting requirements. Based on LPAs interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided. 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 9099A On the allegation facility do not ensure residents are getting meals. Based on interviews the facilities meals are served at regular times each day and if a resident oversleeps or is busy at a mealtime, they will save a plate for them. When asked about special meals or assistance S1 state that the care staff know who needs help with meals and that they have a list of who has dietary restrictions. On the allegation Staff do not ensure medications are dispensed as prescribed for residents in care. Based on interviews the facility staff do dispense medication as prescribed for the residents and logs each dosage given in the medication log. Staff mark if a medication was refused or missed by a resident. 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 this report provided.
Regulation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by:
Inspector finding
Based on observation, LPA observed vomit left uncleaned on the floor.
Regulation
There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidence by:
Inspector finding
Based on records review and observation LPA reviewed staff roster and staff schedules and observed that the facility did not have adequate staffing
Regulation
A written report shall be submitted to the licensing agency and to the person responsible for the resident ... This report shall include...date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidence by:
Inspector finding
Based on observation and interviews the staff working were unaware of how and where to report incidents to licensing.
Regulation
When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.
Inspector finding
Based on records review and interveiws the facility was not following directions made by reisdents doctor.
InspectionApril 25, 2024No deficiencies
Inspector: Alona Gomez
Plain-language summary
On an unannounced visit on April 25, 2024, inspectors looked into an unusual incident report from March 2024 in which a resident received double the prescribed dose of Ativan on two occasions (8 mg instead of 2 mg each time) because the medication's strength had increased but staff gave the same number of tablets as before. The resident experienced no ill effects, the staff member was retrained and disciplined, and no violations were cited.
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On 4/25/2024 at 1:30 PM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a Case Management visit in regards to an unusual incident report received 3/21/2024. LPA met with Executive Director, Teresa Truong and explained the purpose of the visit. CCLD received an unusual incident report dated 3/21/2024 That stated that on 3/17/2024, at approximately 3:00pm and 8:00 pm, R1 was given the wrong dose of medication. On 3/18/2024, Medtech noticed the medication error and notified the Area nurse Manager. R1 was given 8 mg of Ativan at 3:00 pm and 8:00 pm. R1 order is Ativan 2mg: take 2 tablets by mouth three times a day. Physician and responsible parties were notified. LPA spoke with Executive Director who stated that when the medication was renewed the milligrams per tablet went up and the Medtech(S1) did not notice. When giving R1 their medications they gave them the usual amount of tablets not noticing that because of the milligram increase they should have given less tablets. Executive Director acknowledged that it was an oversight and spoke with staff about the importance of paying attention to detail. A training was provided on Medication Procedures and Documentation on 3/20/2024. Medtech(S1) who gave the wrong dosage of medication was written up. Resident sustained no ill side effects. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
ComplaintApril 10, 2024· SubstantiatedType B1 deficiency
Inspector: Alona Gomez
Plain-language summary
A complaint investigation found that the facility violated state regulations regarding how it handles legal documents and powers of attorney. The investigator interviewed staff and residents, and determined there was enough evidence to substantiate the complaint. The facility has been cited and will be required to correct this violation.
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LPA cited for CCR-87466 on complaint 15-AS-20240131134629 and will not be recited on this complaint. Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D
Regulation
(a) A plan for incidental medical and dental care shall be developed by each facility. The ... assistance in obtaining such care...with the following: The licensee shall assist residents ...as needed. This requirement was not met as evidence by:
Inspector finding
Based on interviews LPA was informed that previous Health and Wellness Director was not insuring the availability of medications.
InspectionApril 10, 2024Type A2 deficiencies
Inspector: Alona Gomez
Plain-language summary
A routine annual inspection was conducted on April 10, 2024, and found that the facility maintained adequate lighting, temperature, food supplies, and locked medication storage, with all sampled staff having current first aid training. Two deficiencies were noted: hot water in one bathroom measured at 121.6 degrees Fahrenheit (above the safe standard), and the facility had no records of emergency disaster drills on file. The facility was asked to submit updated emergency disaster plan documents by April 19, 2024.
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On 4/10/2024 at 9:45 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Teresa Truong and explained the purpose of the visit. The facility’s fire clearance was approved for all may be non-ambulatory and 15 bedridden. LPA toured the facility with Executive Director including but not limited to residents apartments, bathrooms, activity room, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 69 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 114.4, 119.5, 121.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Fire extinguisher was last serviced on 2/06/2024. First aid kit was observed to be complete. Emergency disaster drill not on file. At 2:30pm, LPA reviewed 5 residents records. At 3:00pm, LPA reviewed 5 staff records and 5 of 5 have current first aid training and associated to the facility. At 10:25AM , LPA reviewed a sample of resident’s medications. Report Continues on LIC809-C 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 THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 10:40 AM While touring LPA observed Hot water in room 12 measured at 121.6 degrees F At 3:21 PM during File review there are no records of Disaster Drills. Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 4/19/2024: LIC 610E Emergency Disaster Plan (9 Pages) 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. Appeal Rights and a copy of this report provided.
Regulation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degre…
Inspector finding
Based on observation, the licensee did not comply with the section cited above by hot water temperature measuring at 121.6 degrees F which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 04/12/2024 Plan of Correction 1 2 3 4 By POC date Executive Director agrees to adjust water temprature to be in rangeand notify CCLD
Regulation
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill,…
Inspector finding
Based on record review, the licensee did not comply with the section cited above by not having an updated disaster drill log which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 04/19/2024 Plan of Correction 1 2 3 4 By POC date Executive Director agrees to complete Drills and update log and submit a copy of log to CCLD.
InspectionNovember 27, 2023Type B3 deficiencies
Inspector: Alona Gomez
Plain-language summary
During the facility's required annual inspection on this date, inspectors found that one resident's file was missing required documents (safeguards for property, consent form, and personal rights information), all employee files were incomplete, and some staff members were missing required first aid training certifications. The facility otherwise met standards for safety, food storage, medication management, temperature control, and emergency preparedness. The facility was given until December 4, 2023 to submit corrected documentation.
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Licensing Program Analyst (LPA) A. Gomez and Licensing Program Manager (LPM) Y Flores-Larios arrived unannounced to conduct 1-Year Annual Required visit on this date starting at 9:30am. LPA was greeted by Executive Director (ED), Jasmine Seiffert. Health and Wellness Director Cheyenne Flores arrived at approximately 11:00AM during the tour. LPA and LPM toured facility with Executive Director including but not limited to random residents rooms, kitchen, common area and dining area. There were no accessible bodies of water. Hallways and passages were free of obstruction. Comfortable room temperature was maintained at 71 degrees F. Hot water temperature was tested at 115.8 degrees F in one of the bathrooms. Refrigerator temperature measured at 36.3F and Freezer measured at -3F. One week supply of nonperishable and 2-day supply of perishable foods were available and in compliance with regulations. Employee's files and residents files and a sample of medications were reviewed. Employees were fingerprint cleared. Centrally stored medications were locked in medication room. LPA observed a sample of medication. The facility had a written emergency disaster plan dated 11/27/2023. Disaster drill was last conducted on 09/21/2023. Smoke detector and sprinklers were observed throughout facility. Fire extinguisher was last serviced 9/12/2023. ED holds current administrator certificate that expires 7/22/2024 The following deficiencies were observed: At approximately 9:55AM during resident file review R4's file was missing Safeguards for Property/Valuables, Consent Form, and Personal Rights. At approximately 11:50AM during employee file review all employee files were observed incomplete. At approximately 11:55AM during employee file review it was observed that required staff are missing first aid training. 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 Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 12/04/2023: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate Updated facility sketch The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.
Regulation
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
Inspector finding
Based on record review of five staff, the licensee did not comply with the section cited above in having incomplete employee files for 5 of 5 employees records reviewed which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 12/04/2023 Plan of Correction 1 2 3 4 By POC date Executive Director agrees to review and update all employee files and provide a checklist of required documents for each file to CCLD.
Regulation
(b) Each resident's record shall contain at least the following information:
Inspector finding
Based on record review, the licensee did not comply with the section cited above in having R4's file missing the consent form and Appraisal of Needs and Services plan which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 12/04/2023 Plan of Correction 1 2 3 4 By POC date Executive Director agrees to review resident file and update all required forms and submit a self certification to CCLD.
Regulation
87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as th…
Inspector finding
Based on record review of five staff, the licensee did not comply with the section cited above in not having the required staff first aid certified which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 12/04/2023 Plan of Correction 1 2 3 4 By POC date Executive Director agrees to have all required staff first aid trained and certified and submit certificates to CCLD.
ComplaintJuly 27, 2021No deficiencies
Inspector: Lizette Francisco
Plain-language summary
An infection control inspection was conducted on July 27, 2021, and found the facility had appropriate measures in place, including proper screening procedures at the entrance, adequate hand washing stations, staff wearing appropriate protective equipment, and sufficient supplies of protective equipment and food. No violations were found during the visit.
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On 7/27/2021 starting at 2:10pm, Licensing Program Analysts (LPAs) L. Francisco and L. Ibo arrived unannounced to conduct infection control inspection. LPAs met with Executive Director, Glenda Bertucci and explained the purpose of the visit. During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, common areas, and kitchen. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
Federal summary
CMS Care CompareNot a CMS-certified facility
California RCFEs (residential care facilities for the elderly) are licensed by the state, not by CMS. CMS data only applies to skilled nursing facilities or to CCRCs that operate a licensed SNF wing.
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