Inspection Reports for
Brookdale Diablo Lodge

CA, 94526

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Citations (last 5 years)

Citations (over 5 years) 1.4 citations/year

Citations are regulatory findings recorded during state inspections.

65% better than California average
California average: 4 citations/year

Citations per year

4 3 2 1 0
2021
2022
2023
2024
2025

Occupancy

Latest occupancy rate 82% occupied

Based on a November 2025 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Occupancy rate over time

40% 60% 80% 100% Jul 2021 Sep 2022 Mar 2023 Oct 2023 Aug 2024 Jul 2025 Nov 2025

Inspection Report

Complaint Investigation
Census: 105 Capacity: 128 Citations: 1 Date: Nov 5, 2025

Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-08-01 regarding staff supervision and resident care resulting in injury.

Complaint Details
The complaint alleged staff did not ensure care and supervision resulting in resident injury. The allegation was substantiated based on interviews, record reviews, and observations. Other allegations about reporting and room obstruction were unsubstantiated.
Findings
The investigation substantiated that staff failed to provide adequate supervision to a known fall-risk resident, resulting in a serious injury (left hip fracture). The facility did not revise the resident's care plan or implement additional safety measures despite multiple prior falls. An immediate civil penalty of $500 was assessed. Other allegations regarding reporting requirements and room obstruction were found unsubstantiated.

Citations (1)
Facility staff failed to provide adequate supervision to meet resident needs resulting in a serious injury which poses an immediate safety risk to residents in care.
Report Facts
Civil penalty amount: 500 Capacity: 128 Census: 105

Employees mentioned
NameTitleContext
Alona GomezLicensing Program AnalystConducted the complaint investigation and delivered findings
Rachel DavisExecutive DirectorMet with Licensing Program Analyst during investigation and exit interview
William GradyAdministratorFacility administrator named in the report

Inspection Report

Annual Inspection
Census: 104 Capacity: 128 Citations: 0 Date: Jul 9, 2025

Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.

Findings
The facility was found to be in compliance with no deficiencies cited. The inspection included a tour of resident apartments and common areas, review of staff and resident records, and verification of safety and environmental conditions.

Report Facts
Staff records reviewed: 6 Resident records reviewed: 6 Fire extinguisher last serviced: Feb 6, 2025 Disaster drill last conducted: May 12, 2025 Emergency disaster plan last reviewed: Apr 21, 2025

Employees mentioned
NameTitleContext
Rachael DavisExecutive DirectorMet with Licensing Program Analyst during inspection and facility tour
A. GomezLicensing Program AnalystConducted the inspection visit
William GradyAdministrator/DirectorFacility Administrator named in report header

Inspection Report

Complaint Investigation
Census: 105 Capacity: 128 Citations: 0 Date: Jun 5, 2025

Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2025-01-31 alleging issues such as unclean resident rooms, residents left in soiled clothing, and lack of feeding assistance.

Complaint Details
The complaint was unsubstantiated. No deficiencies were cited during the visit. The Licensing Program Analyst was unable to identify any concerns relating to the allegations due to anonymous complainant and lack of specific resident identification.
Findings
The investigation included interviews with a random sample of residents and review of their files. No concerns were identified, residents expressed satisfaction with care, and all rooms were observed sanitary. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

Report Facts
Complaint Control Number: 15 Complaint Control Number Full: 20250131105419

Employees mentioned
NameTitleContext
Alona GomezLicensing Program AnalystConducted the complaint investigation and delivered findings
Rachael DavisExecutive DirectorMet with Licensing Program Analyst during investigation
Navjinder KaurHealth & Wellness DirectorMet with Licensing Program Analyst during investigation

Inspection Report

Complaint Investigation
Census: 104 Capacity: 128 Citations: 0 Date: Aug 7, 2024

Visit Reason
The inspection was conducted as a result of a priority 1 complaint to perform a Health & Safety inspection.

Complaint Details
The visit was triggered by a priority 1 complaint. No deficiencies were cited during the visit.
Findings
The Licensing Program Analyst toured the facility and found no deficiencies. All safety measures including hot water temperature, food supplies, medication storage, smoke detectors, carbon monoxide detectors, first-aid kit, and fire extinguisher were in compliance.

Report Facts
Hot water temperature readings: 110.8 Hot water temperature readings: 113.2 Hot water temperature readings: 109.4 Food supply duration: 7 Food supply duration: 2 Freezer temperature: 0 Refrigerator temperature: 36 Facility capacity: 128 Facility census: 104

Employees mentioned
NameTitleContext
Rachael DavisExecutive DirectorMet with Licensing Program Analyst during inspection
Alona GomezLicensing Program AnalystConducted the Health & Safety inspection
Yvonne Flores-LariosLicensing Program ManagerNamed in report header

Inspection Report

Annual Inspection
Census: 102 Capacity: 128 Citations: 0 Date: Jul 19, 2024

Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate the facility's compliance with regulatory standards.

Findings
The facility was toured and inspected, including resident apartments and common areas. All safety measures such as fire clearance, lighting, temperature, and emergency preparedness were found to be adequate. No deficiencies were cited during the visit.

Report Facts
Hot water temperature: 112.6 Hot water temperature: 109.2 Hot water temperature: 108.9 Freezer temperature: 0 Refrigerator temperature: 36 Fire extinguisher last serviced: Feb 6, 2024 Disaster drill last conducted: Jul 18, 2024 Emergency disaster plan last reviewed: Oct 19, 2023 Staff records reviewed: 6 Staff with current first-aid training: 6 Resident records reviewed: 5

Employees mentioned
NameTitleContext
Rachael DavisExecutive DirectorMet with Licensing Program Analyst during inspection and toured facility
Alona GomezLicensing Program AnalystConducted the inspection visit
Yvonne Flores-LariosLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Capacity: 128 Citations: 0 Date: Nov 1, 2023

Visit Reason
An unannounced complaint investigation was conducted in response to multiple allegations regarding personal rights violations at Brookdale Diablo Lodge.

Complaint Details
The complaint investigation was unsubstantiated for all allegations including inadequate record keeping, failure to address medical condition changes, injuries from falls, failure to follow care plans, improper incident reporting, inadequate care and supervision. The allegation of questionable death was found to be unfounded based on the death certificate indicating death due to chronic congestive heart failure and coronary artery disease, unrelated to neglect by the facility.
Findings
The investigation reviewed multiple allegations including inadequate record keeping, failure to address medical condition changes, injuries from falls, failure to follow care plans, improper incident reporting, inadequate care and supervision, and questionable death. After interviews and document reviews, all allegations were found to be unsubstantiated or unfounded due to lack of preponderance of evidence.

Report Facts
Facility capacity: 128 Dates of resident falls: Multiple unwitnessed falls on 1/28/22, 3/17/22, 8/12/22, and 8/14/22 Investigation visit time: Visit began at 12:45 PM and completed at 1:30 PM on 11/01/2023

Employees mentioned
NameTitleContext
Lizette FranciscoAssociate Governmental Program AnalystConducted the complaint investigation
Paula ArceLife Enrichment ManagerMet with investigator during the visit
William GradyAdministratorFacility administrator named in report header
Harpreet HumpalLicensing Program ManagerNamed as Licensing Program Manager overseeing the investigation

Inspection Report

Annual Inspection
Census: 99 Capacity: 128 Citations: 2 Date: Oct 19, 2023

Visit Reason
The inspection was an unannounced 1-Year Annual Required visit conducted to evaluate compliance with regulatory requirements at the facility.

Findings
The facility was generally compliant with safety and operational standards, including fire clearance, medication storage, and staff training. However, deficiencies were noted regarding the improper storage of PRN medications in residents' apartments, posing immediate health and safety risks.

Citations (2)
Miralax was found in Resident 4's apartment, which is not compliant with centrally stored medication requirements.
TUMS was found in Resident 5's apartment, which is not compliant with centrally stored medication requirements.
Report Facts
Capacity: 128 Census: 99 Plan of Correction Due Date: Oct 20, 2023 Plan of Correction Submission Date: Nov 2, 2023

Employees mentioned
NameTitleContext
William GradyAdministratorFacility administrator named in the report
Rachael DavisExecutive DirectorMet with Licensing Program Analysts during inspection
Alona GomezLicensing Program AnalystConducted the inspection and authored the report
Yvonne Flores-LariosLicensing Program ManagerSupervisor overseeing the inspection

Inspection Report

Complaint Investigation
Census: 104 Capacity: 128 Citations: 0 Date: Jul 10, 2023

Visit Reason
An unannounced complaint investigation was conducted to investigate allegations regarding the facility elevator backup power, staff emergency procedures during a power outage, and staff training on those procedures.

Complaint Details
The complaint involved allegations that the facility elevator did not meet backup power requirements, staff did not follow emergency procedures during a power outage, and staff were not trained on emergency procedures during a power outage. The complaint was found to be unsubstantiated.
Findings
The investigation found that the facility elevator meets backup power requirements, staff followed emergency procedures during the power outage on 07/01/2023, and staff were extensively trained on emergency procedures. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

Report Facts
Facility capacity: 128 Census: 104

Employees mentioned
NameTitleContext
James SampairLicensing Program AnalystConducted the complaint investigation
Rachel DavisExecutive DirectorMet with Licensing Program Analyst during investigation
Jinder KaurHealth & Wellness DirectorMet with Licensing Program Analyst during investigation
William GradyAdministratorFacility administrator named in report header

Inspection Report

Complaint Investigation
Census: 101 Capacity: 128 Citations: 0 Date: Mar 30, 2023

Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2021-11-29 alleging staff did not assist a resident with her incontinence and that the temperature was below the regulated limit.

Complaint Details
The complaint was unsubstantiated based on investigation findings, including staff interviews and observations of temperature controls. No violation was proven.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff interviews indicated residents are checked every two hours and respond to call buttons, and temperature controls in apartments were within regulated limits with smart thermostats set between 65 and 81 degrees Fahrenheit.

Report Facts
Complaint received date: Nov 29, 2021 Facility capacity: 128 Facility census: 101 Inspection start time: 1415 Inspection end time: 1720

Employees mentioned
NameTitleContext
Lizette FranciscoLicensing Program AnalystConducted the complaint investigation
Rachael DavisExecutive DirectorMet with Licensing Program Analyst during investigation
William GradyAdministratorFacility administrator named in report header
Harpreet HumpalLicensing Program ManagerNamed as Licensing Program Manager on report

Inspection Report

Complaint Investigation
Census: 98 Capacity: 128 Citations: 2 Date: Jan 19, 2023

Visit Reason
The inspection was conducted as a result of a Priority 1 complaint to perform a Health & Safety inspection at the facility.

Complaint Details
The visit was triggered by a Priority 1 complaint. The deficiency related to unlocked hazardous materials was substantiated and cited under CCR 87309(a).
Findings
The inspection found unlocked cleaning supplies, bug spray, bleach, gardening tools, oxyclean, and comet in residents' apartments, posing an immediate health and safety risk. Other areas such as hot water temperature, food supply, medication storage, smoke detectors, and fire safety equipment were found to be in compliance.

Citations (2)
Unlocked cleaning supplies, bug spray, and bleach inside kitchen and bathroom cabinets in R1's apartment.
Unlocked gardening tools, oxyclean, and comet observed in R2's apartment.
Report Facts
Hot water temperature readings: 114 Hot water temperature readings: 115.1 Hot water temperature readings: 113.8 Food supply duration: 7 Food supply duration: 2 Facility capacity: 128 Facility census: 98

Employees mentioned
NameTitleContext
Rachael DavisExecutive DirectorMet with Licensing Program Analysts during inspection
Lizette FranciscoLicensing EvaluatorConducted the inspection and signed the report
Harpreet HumpalSupervisorSupervisor overseeing the inspection

Inspection Report

Annual Inspection
Census: 96 Capacity: 128 Citations: 1 Date: Sep 15, 2022

Visit Reason
The visit was an unannounced Infection Control Inspection conducted as a required one-year inspection to evaluate compliance with infection control and safety regulations.

Findings
The facility was found to have adequate infection control measures including screening, PPE supply, and sanitation practices. However, a deficiency was observed where two portable oxygen tanks in a resident's apartment were not secured with stands, posing a potential health and safety risk.

Citations (1)
Two portable oxygen tanks in R1's apartment were observed without a stand, violating oxygen equipment safety requirements.
Report Facts
Staff records reviewed: 5 Staff records with health screening and TB test results: 5 Plan of Correction Due Date: Sep 19, 2022

Employees mentioned
NameTitleContext
Rachael DavisExecutive DirectorMet with Licensing Program Analysts during inspection
Najinder KaurHealth and Wellness DirectorMet with Licensing Program Analysts during inspection
William GradyAdministratorNamed in Plan of Correction agreement to obtain oxygen tank stands

Inspection Report

Complaint Investigation
Census: 90 Capacity: 128 Citations: 1 Date: Nov 18, 2021

Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations that the facility was not kept clean, staff did not assist a resident with hygiene needs, and the facility was malodorous.

Complaint Details
The complaint investigation was substantiated for the allegation that the facility was not kept clean. The allegations that staff did not assist the resident with hygiene needs and that the facility was malodorous were unsubstantiated.
Findings
The investigation substantiated the allegation that the facility was not kept clean, specifically that a resident's room was uncleaned posing a potential health and safety risk. However, allegations regarding lack of hygiene assistance and malodorous conditions were unsubstantiated due to insufficient evidence.

Citations (1)
Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Licensee did not comply by having a resident's room uncleaned which poses a potential health and safety risk.
Report Facts
Capacity: 128 Census: 90 Deficiency Type B: 1

Employees mentioned
NameTitleContext
William GradyExecutive DirectorMet with Licensing Program Analyst during investigation
Grace LukLicensing Program AnalystConducted complaint investigation
Harpreet HumpalLicensing Program ManagerOversaw complaint investigation

Inspection Report

Routine
Census: 81 Capacity: 128 Citations: 0 Date: Jul 28, 2021

Visit Reason
The visit was an unannounced Infection Control Inspection conducted as a required 1-year routine inspection.

Findings
The inspection found the facility to be compliant with infection control standards, including proper PPE use, adequate food supply, and universal screening procedures. No deficiencies were cited during the visit.

Report Facts
PPE supply duration: 30 Food supply duration - perishable: 2 Food supply duration - non-perishable: 7

Employees mentioned
NameTitleContext
William GradyAdministratorMet with Licensing Program Analyst during inspection
Rachel DavisBusiness Office ManagerMet with Licensing Program Analyst during inspection
Lizette FranciscoLicensing Program AnalystConducted the Infection Control Inspection
Harpreet HumpalLicensing Program ManagerNamed in report header

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