Brookdale Diablo Lodge

Type of visit: Required - 1 Year

On 06/16/2026 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Rachael Davis and explained the purpose of the visit. The facility's fire clearance was approved for all may be non-ambulatory of which 8 may be bedridden. LPA toured the facility with Executive Director including but not limited to random 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 75 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured between 106.8-113.2 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. The freezer temperature measured at 0 degrees F and the refrigerator 40 degrees F. Fire extinguisher was last serviced on 2/10/2026. Disaster Drill was last conducted 5/26/2026. Emergency Disaster plan last reviewed 5/1/2026. Smoke detectors and sprinklers are interconnected and observed throughout facility. First aid kit observed complete. LPA reviewed 6 staff records and 6 of 6 are associated and have current first-aid training. LPA reviewed 5 residents records. Updated copies of the following documents were requested for facility file and are to be mailed to CCL by 7/1/2026: 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.the state’s words, verbatim · CDSS document, Jun 16, 2026

Allegation investigated: Staff did not ensure care and super vision was provided resulting in resident sustaining an injury

On 11/05/2025 at 3:00PM Licensing program Analyst (LPA) A Gomez arrived unannounced to deliver findings for the above allegations. LPA met with Executive Director, Rachel Davis and explained the purpose of the visit. During the investigation, the Department conducted interviews with facility staff, residents, and witnesses. Documents obtained and reviewed included R1’s admission agreement, care plan dated 10/13/2023, physician’s report dated 04/18/2024, staff schedules for February and March 2024, medication logs, incident reports for falls occurring on 3/25/2024, 1/9/2023, and 6/10/2022, discharge notes dated 2/29/2024, and corrective action plans. Photographs of R1’s room were also provided by W1 for review. Report continues on LIC9099-C Substantiated Pg 2 On 3/25/2024, R1, a known fall risk according to care plan dated 10/13/2023, had a fall in their room while attempting to change into their pajamas. S1 reported hearing R1 call for help and found them on the floor near their bed. S1 stated, “R1 said they lost their balance and fell. I usually remind them to press the pendant, but I didn’t see them before they fell.” S3 and S4 responded to the radio call and assisted R1. S4 reported that R1 said, “It hurts. It hurts. I fell,” and also, “Get me off this floor.” S1 and S4 helped R1 into a recliner, after which S4 called 911. Medical records obtained confirmed that R1 sustained a left hip fracture requiring surgical intervention. W1 expressed dissatisfaction with staff supervision and stated, “R1 had told me before that no one checked on them as much as they should. This isn’t the first time R1 has fallen, and it shouldn’t have happened.” R1 experienced multiple falls before 3/25/2024, including incidents on 8/7/2019, 1/1/2020, 1/15/2021, 6/11/2022 and 9/1/2023. Despite these incidents, the facility failed to revise R1’s care plan or implement additional safety measures. S1 stated, “I usually remind them to press the pendant.” S1 also reported that R1 would place their walker by the door, and that they typically checked on R1 four times per shift. S2 stated that R1 required help with showers, dressing, toileting, blood sugar checks, and escort assistance. S2 added, “R1 was changing into their pajamas when they fell and did not press their pendant for help.” Report Continues on LIC9099-C Pg. 3 S3 confirmed that residents at risk of falling are required to be checked every 30 minutes, minimize environmental clutter, and use call pendant for assistance. S3 noted, “The facility does not have any real fall prevention methods in place for residents.” S3 added, “R1 began losing their balance but refused staff’s help. They had a walker but refused to use it and held onto rails in the facility for balance.” S4 reported that staff check call pendants monthly for functionality and all residents are expected to wear them 24/7. S4 stated, “The facility does not have other fall prevention equipment such as fall mats as not a lot of residents are considered a fall risk.” Interviews revealed that R1’s pendant was often left on their nightstand rather than worn or kept within reach. Incident reports for R1’s prior falls, including the fall on 1/15/2021, without follow-up details or documentation of corrective actions. Facility records provided did not show that R1s previous falls resulted in a reassessment of R1’s care needs or adjustment to their supervision. Staff, including S1 and S3, noted that R1 had become increasingly withdrawn in the month prior to the incident. S1 shared, “In the last month or so before R1 left the facility, they became very withdrawn, sad, and cried all the time. R1 told me that their son was sick.” However, there was no evidence of additional emotional support being provided, nor documentation of care planning to address R1’s reduced help-seeking behavior. Records and interviews overall did not have proactive, consistent strategies to mitigate R1’s known fall risk despite repeated incidents and observed decline. ****An immediate civil penalty of $500 is being assessed on today’s date. Civil penalty determination related to serious bodily injury is pending. **** Based on LPAs observations and interviews which were conducted and record reviews, 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.Exit interview conducted with Executive Director. A copy of this report and appeal rights was provided. Pg. 2 On the allegation “Staff did not ensure reporting requirements were followed.” The fall involving R1 on 3/25/2024 was reported via LIC 624 to Community Care Licensing and documented in the facility’s records. Staff interviews confirmed that after the incident, notifications were made to R1’s physician, responsible party, and emergency services in accordance with regulatory requirements. Specifically, records show that R1’s physician was notified via facsimile at 20:00 hours, and their POA was contacted via telephone at 16:20 hours. Although the reporting party stated they were initially told that the incident had been reported to Licensing when it had not, the Department verified that a report was submitted by the facility within the appropriate timeframe. On the allegation “Staff did not ensure resident room was free from obstruction” The Department reviewed photographs of R1’s room submitted by W1 and conducted a review of the facility’s safety practices regarding environmental hazards. While W1 expressed concern regarding clutter in R1’s unit, staff interviews revealed that fall prevention strategies included reminders to reduce clutter and arrange furniture to allow for safe walkways. The Personal Service Plan dated 10/13/2023 stated, "Encourage R1 on reducing environmental clutter and arrange furniture for adequate walkways." Interviews with staff who responded to the fall did not indicate that obstructions or clutter directly caused or contributed to the incident on 3/25/2024. S3 stated that R1 was found close to their bed, and S4 confirmed that R1’s room did not appear to be cluttered during the response. Based on observations, photographs, interviews and file review the allegations above 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. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Nov 5, 2025 · control 15-AS-20240801083129

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 5, 2025

(a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirment was not met as evidence by Based on interviews and record review the staff acknowledged that R1 was a fall risk as identified in (list the documents that support this) and facility staff failed to provide adequate supervision to meet R1 needs resulting in a serious injury which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 5, 2025

Plan of correction: Facility has hired and trained additional staff. $500 civil penalty assessed

Type of visit: Case Management - Other

On 11/05/2025 at 5:00 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a case management review related to complaint 15-AS-20240514173549. Upon arrival, LPA met with Executive Director, Rachel Davis, and explained the purpose of the visit. During the course of the investigation, The Department conducted interviews, and reviewed files. It was discovered R1 had several falls while at the facility occurring on 3/25/2024, 1/9/2023, and 6/10/2022 and that the facility did not update R1 care plan after subsequent falls to address R1’s change of condition and care needed. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING INVESTIGATION: Facility did not update residents care plan when there was a change in condition 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.the state’s words, verbatim · CDSS document, Nov 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Nov 19, 2025

(a)The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidence by: Based on interviews and record review facility staff did not adhere to the requirement above of conducting a reappraisal after R1 sustained multiple falls on 6/10/2022, 1/9/2023, or 3/25/2024 to address change in condition which poses a potential safety risk to clients in care.the state’s words, verbatim · CDSS document, Nov 5, 2025

Plan of correction: By POC date Facility agrees to review regulation above. Review current resident roster and identify residents with unidentified care needs that are not addressed in existing appraisal. Notify CCLD of residents identified and dates reappraisals will be conducted.

Type of visit: Required - 1 Year

On 07/9/2025 at 8:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Rachael Davis and explained the purpose of the visit. The facility's fire clearance was approved for all may be non-ambulatory of which 8 may be bedridden. LPA toured the facility with Executive Director including but not limited to 6 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. The hot water temperature in a sample of residents’ shared bathroom were 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. The freezer temperature measured at 0 degrees F and the refrigerator 40 degrees F. Fire extinguisher was last serviced on 2/06/2025. Disaster Drill was last conducted 5/12/2025. Emergency Disaster plan last reviewed 4/21/2025. Smoke detectors and sprinklers are interconnected and observed throughout facility. First aid kit observed complete. LPA reviewed 6 staff records and 6 of 6 are associated and have current first-aid training. LPA reviewed 6 residents records and a sample of medications reviewed. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 9, 2025

Allegation investigated: Staff do not ensure residents room is kept clean Staff allowed resident to be left in soiled clothing for an extended period of time Staff do not provide resident with feeding assistance

On 6/05/2025 at 1:20 PM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to continue the complaint investigation and deliver findings for the above allegations. LPA met with Executive Director, Rachael Davis and Health & Wellness Director, Navjinder Kaur, and explained the purpose of the visit. During the course of the investigation the LPA chose a random sample of residents to interview, and review their files. LPA interviewed R1, R2, R3, and R4. All residents expressed satisfaction with the care and assistance provided by the facility and staff. Because no resident was specified in the complaint and RP remained anonymous LPA was unable to identify a specific resident. LPA was unable to identify any concerns relating to the allegations. All residents and rooms were observed sanitary. 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. Nothe state’s words, verbatim · CDSS document, Jun 5, 2025 · control 15-AS-20250131105419

Type of visit: Case Management - Health Checks

On 08/07/24 at 5:50 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Executive Director, Rachael Davis and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature in random resident apartments was measured at 110.8, 113.2, and 109.4 degrees F. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies on a weekly basis. The freezer temperature measured at 0 degrees F and the refrigerator 36 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 02/06/2024. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 7, 2024

Type of visit: Required - 1 Year

On 07/19/2024 at 9:20 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Rachael Davis and explained the purpose of the visit. The facility's fire clearance was approved for all may be non-ambulatory of which 8 may be bedridden. LPA toured the facility with Executive Director including but not limited to 6 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 74 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured at 112.6, 109.2, 108.9 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. The freezer temperature measured at 0 degrees F and the refrigerator 36 degrees F. Fire extinguisher was last serviced on 2/06/2024. Disaster Drill was last conducted 7/18/2024. Emergency Disaster plan last reviewed 10/19/2023. Smoke detectors and sprinklers are interconnected and observed throughout facility. LPA reviewed 6 staff records and 6 of 6 are associated and have current first-aid training. LPA reviewed 5 residents records. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 19, 2024

Allegation investigated: Personal Rights - Facility has inadequate record keeping of a resident while in care Personal Rights - Staff did not address a resident change in medical condition Personal Rights - Resident sustained injuries from multiple falls while in care Personal Rights - Staff did not follow a resident's care plan while in care Personal Rights - Staff did not properly report incidents involving a resident Personal Rights - Staff did not provide adequate care and supervision to a resident

On 11/1/2023 starting at 12:45 PM, Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to deliver findings for the above allegations. AGPA met with Life Enrichment Manager, Paula Arce and explained the purpose of the visit. During course of the investigation, the Department conducted interviews with facility staff, witness and complainant. Documents including but not limited to: R1’s physician’s report, care plan, medication log, incident reports, hospice care notes, progress notes, and death certificate were obtained. Allegation: Personal Rights - Facility has inadequate record keeping of a resident while in care However, based on record review of R1’s progress notes and incident report, AGPA observed a history of notes by staff regarding R1’s fall and any changes in condition observed from March of 2022 to August of 2022. REPORT CONTINUES ON 9099C Unsubstantiated Allegation: Personal Rights - Staff did not address a resident change in medical condition However, based on interview with staff and W1, hospice was notified whenever staff observed a change in condition and nurse from hospice was requested by facility to assess resident. R1 was admitted to facility on January of 2022 and AGPA observed Personal Service Plan was updated, 3/4/22, and 8/22/2022 to address R1’s change in condition. Allegation: Personal Rights - Resident sustained injuries from multiple falls while in care Based on record review of incident report and progress notes, R1 had multiple unwitnessed falls on 1/28/22, 3/17/22, 8/12/22, and 8/14/22. However, no injuries were noted. R1 was admitted to ER on 3/17/22 and xray was completed, but no fractures were sustained from the fall. Allegation: Personal Rights - Staff did not follow a resident's care plan while in care Based on interview with W1, facility was following resident’s care plan and was in communication with hospice. W1 did not feel that there was any neglect by the facility according to the records from the nurses in charge during the time R1 was under hospice care. Allegation: Personal Rights - Staff did not properly report incidents involving a resident Based on record review, responsible party was notified of R1’s multiple falls that occurred on 1/28/22, 3/17/22, 8/12/22, and 8/14/22. Allegation: Personal Rights - Staff did not provide adequate care and supervision to a resident Based on record review, facility addressed the concern with R1’s responsible party regarding R1’s multiple falls. A care conference was held on 8/15/2022 where facility recommended a 1:1 companion for R1 due to increased agitation. However, R1’s responsible party refused. R1 was being checked by staff every 2 hours. 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 report provided to Life Enrichment Manager. Allegation: Personal Rights - Questionable Death The Department obtained a copy of R1’s death certificate where it indicates that the cause of death was due to chronic congestive heart failure and coronary artery disease. R1 was admitted to hospice on July 25, 2022 and was diagnosed with heart failure and not related due to neglect of the facility. This agency has investigated the complaint alleging questionable death. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report provided to Life Enrichment Manager.the state’s words, verbatim · CDSS document, Nov 1, 2023 · control 15-AS-20230118130142

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) A. Gomez and Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to conduct a 1-Year Annual Required visit on this date starting at 10:40AM. Upon arrival, LPA and AGPA met with Executive Director, Rachael Davis. The facility's fire clearance was approved for all may be non-ambulatory of which 8 may be bedridden. LPA and AGPA toured the facility inside and out with Executive Director including but not limited to facility hallways, activity room, dining room, kitchen, resident rooms and medicine room. Indoor and outdoor passageways were kept free of obstruction. There are no bodies of water observed. Hot water temperature in random resident's bedroom was maintained at 113.6 degrees F. In another Residents room, hot water temperature was maintained at 114.1 degrees F. A comfortable room temperature was maintained at 73 degrees F in the hallway. Facility was equipped with a minimum of one week supply of non-perishable and 2-day supply of perishable food. Medication carts were observed locked. LPA's reviewed a sample of medication. Fire extinguisher was last serviced on 09/12/2023. Smoke detectors and sprinklers are interconnected and observed throughout facility. LPA and AGPA reviewed 5 staff records and 5 of 5 are associated and have current first-aid training. LPA reviewed 5 residents records. The following deficiencies were observed At 12:17PM LPA's observed Miralax in R4's apartment. At 12:35PM LPA's observed TUMS in R5's apartment. REPORT CONTINUES ON 809C Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 11/02/2023: LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate 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 with Executive Director. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 19, 2023

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.