Brookdale San Ramon

On 4/18/2025 at approximately 11:15AM, while at the facility on an unrelated complaint investigation LPA A Gomez conducted a case management visit. LPA met with Executive Director, Lola Bullock and explained the purpose of the visit. Upon arrival at the facility LPA met with Executive Director (ED) Lola Bullock and the ED disclosed to LPA that on 4/17/2025 at approximately 6:00PM R1 left the facility in their wheelchair and tried to roll themselves into traffic. ED states R1 is unable to leave the facility unassisted according to their physicians report and that when R1 exited the facility the front desk and other staff followed to ensure their safety. ED states that R1 has a history of suicidal ideations and provided LPA with substantiating documentation. ED notified the police and had R1 transferred to the hospital to be put on a 5150 hold. ED states that due to R1's continues attempts at self harm that they are requiring a 1 on 1 supervision in order for R1 to return to the facility to ensure the safety of the resident. At the beginning of the visit ED informed LPA that R1 is currently at the hospital and LPA advised ED to notify R1's responsible party and update R1's care plan for return. LPA observed that R1's 602 dated 10/4/2023 states that R1 has a history of depression, suicide, and elopement. While at the visit ED received an update that R1's family has decided to move R1 to a facility with a higher level of care. LPA requested to be informed of any updates. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On the allegations “Improper eviction” “Resident needs are not being meant” “Staff left resident in soiled diaper” “Facility is not providing services that are being charge” “Facility is not proving resident proper meal” “Resident is being isolated” “Resident room is being used as staff break and or storage room” “Facility is short staffed” the following was found: On 01/14/2025, LPA conducted interviews with R1 and the Executive Director at the time Niare Feaster (ED), reviewed documentation including R1’s admission agreement, care plan dated 10/13/2023, physician’s report dated 04/18/2024, facility billing records, eviction notice, and staff schedules. Facility observations were also conducted. R1 stated they feel there are not enough staff and expressed a desire for more one-on-one interaction, including being accompanied to the activities area every Wednesday at 1:00 PM. R1, who identifies as largely independent, shared they self-administer medication and often decline bathroom assistance. They clarified they do not receive diapering services as part of their care plan and care plan reflects that they do not require incontinence care. R1 reported requiring nighttime toileting assistance due to wheelchair access challenges. R1 also shared concerns about having occasionally forgotten to request meals, resulting in limited options such as toast or pie. R1 expressed dissatisfaction with being billed for services such as oxygen management and bathing, which they believe are not provided. Review of records showed R1 was admitted on 10/13/2023, with a base rate of $7,413.00 per month. The total amount billed through February 2024 was $46,630.62 including late fees, with only two successful payments made since admission, as reflected in the payment history. The ED explained that the oxygen service billed is the facility’s base rate for residents with oxygen, which includes documentation but no hands-on management or intervention. ED stated that toileting assistance remains on the service plan, however R1 seldom uses it and has declined its removal. Report continues on LIC9099-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 LIC9099-C Regarding the eviction, a 30-day notice to quit was issued on 02/02/2024 for non-payment of rent. Staff schedules for February and March 2024, were reviewed by LPA and LPA observed that enough staff were scheduled. LPA also observed an adequate amount of staff at the time of both visits. While R1 reported feeling that more staff would improve their experience, interviews and documentation confirmed no lapses in care or supervision. Observations conducted during the facility visit found R1’s room appropriately maintained and free of any signs it was being used for staff breaks or storage. There were no indications of inappropriate use of the resident’s private space. There was no evidence to support the allegation that staff left R1 in a soiled diaper, and this is further unsupported by the fact that R1 does not receive diapering assistance as part of their care plan. Regarding meals, kitchen staff reported that residents must request meals outside of scheduled times and that snacks, including pie, are available when full meals are not requested. R1 stated that they do forget to order meals sometimes and only wants toast or other small items from the options available. Finally, R1 stated that they remain in their room by choice due to pain and mobility limitations and may request assistance to participate in activities. ED did inform LPA that while staff provide escorts to R1 when available if they would like that to be apart of their care plan it would be an additional charge. Based on interviews, record review, and observations the above allegations are UNSUBSTANTIATED Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED .

In regard to the allegations " Facility staff did not notify responsible party of change in condition " and " Facility staff serve poor quality food "LPA interviewed S3, S4, S5, S6, and Health and Wellnes Director. S3 was not a staff member at the time of R1's admission but stated that the quality of the food is good. S3 described the food as really good. S3 states that the menu choices are good. S3 has eaten the food and says that they are good; sometimes a little bland but nothing that salt and pepper cant fix. S4 stated that the resident never expressed unhappiness to them about anything. States that when resident would complain about the food they would say it sucks and that they would just agree with the resident . States that they have had the food a few times but that it was nothing memorable. S5 states that R1 never expressed any information about their private life. States that the R1 seemed happy. States that R1 would talk about problems with their jobs and going to court with their spouse but that they would be smiling when discussing it. S5 states that they were surprised to find out about R1 incident. States that R1 would complain about the food and quality and that they(S5) would apologize. S5 states that they have tried the food and that they do not like it. States the food is bland, tuff, and greasy. S6 states that they are trained to look for a change in behavior but was unable to specify in regard to mental health. S6 states that they heard about R1's incident and that when looking at the chart they could see that they had a history of depression. However S6 did not ever work with R1. States that it is very common for residents to complain about the food. States that residents complain about the meat being dry and tough. When LPA interviewed HWD they stated that R1 did not exhibit any change in their routine and that when they(R1) were admitted they were already going through stressors and it was not something new that occurred while at the facility. HWD states that R1 was an independent resident and also a private person. R1 would talk about what they were dealing with in life but never expressed being distressed. HWD states that on the day of the incident with R1 there was no change in their routine. HWD states that R1 had a therapist that they would work with and observed R1 utilizing coping mechanisms such as taking walks. Report Continues on LIC9099-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 LPA reviewed the 602 for R1 and observed that they did not have a diagnosis of depression and had a secondary diagnosis of anxiety. On 12/16/2024 LPA observed the food being served to the residents and utilized the Business Manager as a taste tester. The food observed was beef stew, rosemary chicken, bbq chicken, lasagna, and carrots. LPA cut each piece and had no difficulty. The business manager sampled each item and stated that they were easy to chew and had a pleasant taste. LPA asked the chef how each item was seasoned and the chef showed the LPA a variety of seasonings and stated that they also used low sodium seasoning. The food looked appetizing and had a pleasant smell. LPA also observed table salt and pepper available at all dining tables for use. On 3/27/2024 LPA briefly spoke with a R3, R4, and R5 during lunch hour who all stated that they like the food at they facility and have no complaints. Based on interviews, observations, and record reviews the allegations are UNSUBSTANTIATED . Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED .

On 3/20/2025 at 11:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Niare Feaster and explained the purpose of the visit. The facility’s fire clearance was approved for 82 non-ambulatory and 28 ambulatory on the third floor. LPA toured the facility with Niare Feaster including but not limited to 5 residents apartments, bathrooms, multiple activity rooms, 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 xxx 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 104.8, 112.6, 109.2, 108.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. Refrigerator temperature: 38 Freezer temperature:0 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. Emergency disaster plan last reviewed 3/10/2025. First aid kit observed to be complete. Fire Extinguishers scheduled for service 3/8/2024. At 12:30pm, LPA reviewed 5 residents records. At 1:00pm, LPA reviewed 5 staff records and 5 of 5 have current first aid training and associated to the facility. At 11:45am, LPA reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

LPA also interviewed the health and wellness director (HWD) who stated that R1 was told that they could not return to the facility with a stage 3 wound. ED and HWD both stated that the resident could return once the wound was no longer a stage 3. There was no documentation available for the LPA to review the official diagnosis of the wound. Title 22 s tates , " (a)Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or r e tained in a residential care facility for the elderly:(1)Stage 3 and 4 pressure injurie s " . R1 never received an official eviction letter and relatives removed R1's belongin gs. Therefore the allegation " Illegal eviction" is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided.

ED states that eviction letters resemble a bill and when LPA interviewed R1 they stated that they got a bill not an eviction letter. LPA also interviewed S1 who stated that they have never heard staff speak to any residents directly about being evicted. S1 states that they do recall a conversation with R1 and the topic of eviction but that R1 was talking to other residents about it during meal time. R2 and R3 do not recall hearing about a resident being evicted. On the allegation of staff not meeting residents needs LPA interviewed R1, R2, and R3. R2 and R3 both felt that their needs are met at the facility. When LPA interviewed R1 it was found that R1 felt that their needs were not being met but that it was their personal caregiver that was supposed to be providing a 1:1 that was not meeting their needs and that they had no complaints with the facility staff. LPA also obtained a copy of what an eviction notice looks like for reference. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED .

On 08/09/2024 at 1:50 p.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit due to receiving an Unusual Incident Report (UIR) of a resident having attempted suicide. LPA met with Niare Feaster , Executive Director and explained the purpose of the visit. R1 was admitted to the facility on 9/29/23. Physician's Report dated 6/07/24 indicates that R1 was independent and could leave the facility unassisted. Report indicates that R1 was not at risk of accessing personal grooming supplies. The report also documented that R1 did not have any suicidal ideations. ED stated that R1 had 2 cuts about 1 inch each and that the cuts did not require stiches. Resident is still on a 5150 hold and has not returned to the facility. R1 refused to be transported to the hospital and received first aid from the EMT's. RP was notified of incident and came to the facility to speak to ED and at that time R1 admitted that the cuts were self inficted and that they planned on doing it again. ED notified law enforcement and R1 was 5150 when EMT's returned. R1 is to be reassessed before returning to the facility. RP and ED will determine the best course of action and develop a new care plan as needed. Health and Wellness Director filed an UIR and informed LPA via phone of the incident. LPA toured R1's room with S1 and observed it to be within regulation standards. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 6/06/24 at 10:45 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit due to receiving an Unusual Incident Report (UIR) of a resident having committed suicide. LPA met with Jennifer Gordon-Alvarez, Health and Wellness Director and explained the purpose of the visit. During the visit LPA interviewed S1, reviewed R1's facility file and toured R1's room. R1 was admitted to the facility on 11/14/23 from a rehab facility due to having suffered a stoke. Physician's Report dated 6/16/23 indicates that R1 was independent and could leave the facility unassisted. R1 also managed his own medications. The report also documented that R1 did not have any suicidal ideations. S1 stated that R1 routinely took walks on the hill behind the facility. S1 stated that on 6/04/24 at around 5 p.m. she received a call from a friend of R1. The friend stated that he had called R1 numerous times throughout the day and haven't heard back from him. S1 searched for R1 and found him slumped over on the trail behind the facility. S1 observed a small handgun next to R1. S1 called 911, police and paramedics arrived and pronounced R1 decreased from an apparent suicide. S1 filed an UIR and called the facility's LPA to inform her of the incident. LPA toured R1's room with S1 and observed it to be neat and orderly with several personal items. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 8/10/2022 at 1:40 PM, Licensing Program Analysts (LPAs) L. Francisco and P. Watson arrived unannounced to conduct Infection Control Inspection. LPAs met with Executive Director, Akindele Omole and Carolyn Appeal, and LPAs explained the purpose of the visit. During the Infection Control Inspection, LPAs toured facility with Executive Director and Wellness Director including but not limited to front entrance, screening station, hand washing stations, a sample of apartments, common areas, kitchen and backyard. 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. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, and paper towel. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. At 3:05 PM, LPAs reviewed 5 staff records and 5 of 5 have TB test on file. Facility has a mitigation plan and maintains record of routine screening for residents and staff. No deficiencies cited during visit. Exit interview conducted with Wellness Director. A copy of this report provided.

Information obtained alleging resident not accorded dignity in their relationship with staff. Based on interview with 5 residents, 5 of 5 residents stated staff are great and meet their needs. S1 stated if residents want to talk to Executive Director (ED) directly, ED's office door is always opened or residents can request staff for ED. 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.

Information obtained alleging staff makes inappropriate comments towards residents. However, 5 of 5 residents said staff never made inappropriate comments towards residents nor witnessed staff making inappropriate comments towards other residents. Although the allegations may have happened or is valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED .