Brookdale North Fremont

On 07/16/2025 at 10:15 AM, Licensing Program Analyst (LPA) P.Manalo arrived unannounced to conduct a case management visit due to receiving a self report of an SOC341 of a resident's hygiene needs not being met and the lack of documentation of resident's change in condition. LPA met with Health and Wellness Director, Jeffery Jackson, and explained the purpose of the visit. During the visit, LPA observed Resident 1's (R1's) room having a strong smell of urine. However, LPA observed R1's mattress in clean linens and R1 in clean clothing in the dining hall. LPA interviewed Health and Wellness Director and 4 staff. LPA attempted to interview 3 other staff but was unavailable during today's visit. LPA reviewed and obtained R1's after visit summary, internal incident report, physician's report, personal service plan, prescription order, progress notes, third party collaboration notes, staff schedule, staff contact list, and SOC341. LPA may return at a later time. No deficiencies cited. Exit interview conducted and a copy of this report provided.

On 07/30/2021 at 9:03am, Licensing Program Analysts (LPAs) A. O'Hollaren and J. Clancy-Czuleger arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator Lady Reed and explained the purpose of the visit. During the inspection, LPAs toured facility including but not limited to common areas, hand washing stations, bedrooms, kitchen and courtyard. LPAs observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPAs observed PPE, food and paper supplies are sufficient. COVID-19 screening questions were maintained at the facility for all staff, residents, and visitors. Hand sanitizer is provided at facility entryway. Common areas are disinfected frequently throughout the day. A carbon monoxide detector was tested and was observed to be working. Smoke detectors are interconnected to the Fire Department. During record review, LPAs observed facility has a copy of Mitigation Plan on file. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

Page 2 Allegation: Residents are not being showered timely. All 5 staff interviewed stated the residents are showered 2 or 3x per week depending on the resident’s Care Plan. If resident refused, they endorse and report to their supervisor and med-tech and the next shift care staff will try to provide shower. During investigation, LPA observed the residents were clean. Due to medical diagnosis, LPA was not able to obtain information from the 2 residents. Therefore, the allegation is closed as unsubstantiated. Allegation: Residents are not being changed timely. All the 5 staff interviewed stated residents are changed 2 to 3x times during their shift and as needed. PED stated there are some residents who still can go to the bathroom but residents are checked every 2 hours and diapers are changed as needed. LPA didn’t observe resident with urine odor. Due to medical diagnosis, LPA was not able to obtain information from the 2 residents. Therefore, the allegation is closed as unsubstantiated. Allegation: Residents needs are not being met due to a lack of staffing Reporting party (RP) stated that the laundry was not being done. RP also stated the activity director is cooking, because the cook quit and sometimes care staff were pulled to cook. All the 5 staff interviewed stated they were never pulled from the floor to cook. When the cook quit, S1 came on board to do the cooking. LPA interviewed S1 who confirmed he was the pro tem cook at that time. ........continued on 9099C (page 3) 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 Page 3 The 5 staff including the PED stated the residents never run out of clean clothing. The PED also stated the facility has 2 washers and it never happened that both are broken at the same time. When one is broken, it gets fixed right away. Two of the 5 staff stated they remember there was a year when the laundry machines were broken but the residents never run out of clean clothing because the laundry were dropped off and picked-up from the laundry service location by care staff assigned and were already washed and folded when picked-up. The 5 staff stated that during the previous years when facility had COVID-19 outbreaks and staff called off, the facility contracted with staffing agency. The PED stated that when she came on board in 2024, they didn't have problem with staffing and didn't utilize staffing agency. Due to medical diagnosis, LPA was not able to obtain information from the 2 residents. Therefore, the allegation is closed as unsubstantiated. Allegation: Staff are not following COVID protocols. RP stated there’s no designated area for the COVID-19 positive residents and staff work on both positive and negative residents. All 5 staff interviewed stated there was no cross-over of care staff from positive residents to negative residents or vice versa. The facility followed the protocol and guidance from Public Health, Community Care Licensing and Brookdale corporate. All these staff including the PED stated residents who tested positive of COVID-19 were isolated. They stated some residents who were on isolation due to medical diagnosis came out of isolation but when this happened, they redirected the residents back to their rooms or separate them from the negative residents in the common area. Due to medical diagnosis, LPA was not able to obtain information from the 2 residents. Therefore, the allegation is closed as unsubstantiated. ......continued on 9099C (page 4) 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 Page 4 Based on interviews, observation and records reviews, the four allegations were closed as unsubstantiated as t here 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.

Continued from LIC9099 The facility followed protocol by investigating, notified R1's responsible party (RP), CLLD and hospice agencies involved. LPAs was unable to interview R1 during visit due to a dementia diagnosis. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore this allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted. A copy of this report provided.

On 06/06/2025 at 11:50 AM, Licensing Program Analyst (LPA) P.Manalo arrived unannounced to conduct a case management visit in regards to death report received on 06/02/2025. LPA met with Executive Director, Simone Hall, and explained the purpose of the visit. Death Report indicated that Resident 1 (R1) was found unresponsive during room rounds and first responders pronounced R1 deceased at around 2:53 AM. LPA obtained R1's Physician's Report, Service Plan Report, and Physician's Fax Report of Falls. R1 had sustained multiple falls within the last couple months with no apparent injuries. Executive Director stated that the facility implemented for staff to do more check-ins with R1 at night, and usually R1 would be in the activity room throughout the day. Executive Director will reach out and obtain a death certificate. Executive Director will notify LPA once obtained. LPA may return at a later time. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.

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 -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. 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) 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. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 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. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 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 unsubstantiate d. 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. 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 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 and staff medication training records. LPA interviewed the previous ED and staff (S3, S4 and S5) and resident's personal companion. RP reported that S2 who is not a med-tech administered medications to residents. ....continued on 9099C (page 2) 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. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office , 1515 CLAY STREET, STE. 310 OAKLAND , CA 94612 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.

On 7/23/24 at 10:20 am Licensing Program Analysts (LPA) J. Clancy-Czuleger P. Manalo arrived unannounced to do an annual inspection. LPA meet with Executive Director Simone Hall and explained the purpose of the visit. LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, courtyard. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 4/31/2024. At 11:02 am LPA reviewed 6 residents records. At 12:05 pm, LPA reviewed 4 staff records and 4 of 4 were fingerprint cleared and associated to the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

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 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.

On 12/9/2022, at 9:10AM, Licensing Program Analysts (LPAs) L. Fici and J. Clancy-Czuleger arrived unannounced to conduct a case management visit for an incident that occurred on 11/8/2022. LPAs was greeted by ANGIE R. CHANEY , Administrator (ADM) and explained the purpose of visit. LPAs received an Soc341 that was submitted to CCL on 11/14/2022. LPAs interviewed ADM regarding the incident. ADM verified that there was no injuries that the resident sustained, nor any bruising or marks on residents body. No pictures or videos were taken of the incident. Facility held an investigation on 11/8/2022 and investigation closed on 11/8/2022. The companion of the resident was from Glenmoor home care and was working one on one with resident. Companion of the resident is no longer allowed in Brookdale North Fremont as of 11/8/2022 because of the incident that occurred. No deficiencies cited during visit. Exit interview conducted with administrator, and a copy of this report provided.

Continued from LIC9099. R1's change of condition. LPA reviewed progress notes from the facility and the hospice agency. Hospice notes dated 5/12/2024 stated there would be a follow-up visitor for R1's fall which occurred on 5/11/2024. Progress notes dated 5/30/2024 indicated there was a conversation with R1's responsible party about increased needs. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On today’s date, at 11:50 AM, Licensing Program Analyst (LPA) L. Fici and Licensing Program Manager (LPM) Y. Flores-Larios arrived unannounced to conduct an Annual Infection Control Visit. LPA and LPM was greeted by Administrator- Angie Chaney and Health and wellness director Chiquita Morris at the front door entrance. During the inspection, LPA and LPM toured facility including but not limited to front entrance, kitchen, common areas, hand washing station, bedroom and bathroom. LPA and LPM observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA and LPM observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days perishable food supply. All sharps and toxins were locked up and inaccessible to residents in care. Common areas are disinfected frequently throughout the day. Water temperature is measured at 115.6. Fire extinguisher was last serviced on 4-25-2022. Carbon monoxide and smoke detector are operable. Facility passages inside and out free of obstruction and does not pose a health and safety risk for persons in care. During record review, LPA and LPM observed facility has a copy of their Infection Control Plan on file. No deficiencies cited during visit. Exit interview conducted with Administrator and health and wellness director. A copy of this report provided.