Brookdale Danville

(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: 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.

(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 provision of adequate services.This requirement was not met as evidence by: 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.

(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: 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.

(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours.... subject to the requirements in Sections 87412(f), 87506(d), and 87508(b)This requirement was not met as evidence by: Based on interview with Operations Specialist, Dimple Kamdar the facility is refusing to provide corrective actions/ writeups issued to staff which poses a potential personal rights violation to residents in care.

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: Based on observation, LPA observed vomit left uncleaned on the floor.

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: Based on observation and interviews the staff working were unaware of how and where to report incidents to licensing.

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. Based on records review and interveiws the facility was not following directions made by reisdents doctor.

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: Based on records review and observation LPA reviewed staff roster and staff schedules and observed that the facility did not have adequate staffing

(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: Based on interviews LPA was informed that previous Health and Wellness Director was not insuring the availability of medications.

Licensees who accept and retain residents with dementia shall be responsible for... the following: There is an adequate number of direct care staff to support each resident’s ... needs as identified in his/her current appraisal.This requirement is not met as evidence by: Based on observation and interviews there was not adequate staffing to meet residents needs.

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.

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.

Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not safeguarding resident's belongings which poses a potential health and safety risk to the persons in care.

The licensee shall ensure that residents are regularly observed for changes in physical ... such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.This requirement is not met as evidence by: Staff was not notifing residents responsible party ofchanges in residents conditions

Personal Rights of Residents in All FacilitiesThis requirement is not met as evidenced by: Based on observation and interviews residents rooms are locked and most residents do not have a key and must ask to get let in which poses a potential health and safety risk to the persons in care. .

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.

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.

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.