157203395-12-21-2021-24-AS-SPIY-CA4PUL-20211227103739

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157203395
Report Date: 12/20/2021
Date Signed: 12/21/2021 04:13:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2021 and conducted by Evaluator Darius Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20210907082850

FACILITY NAME:	BROOKDALE RIVERWALK		FACILITY NUMBER:	157203395
ADMINISTRATOR:	WEBSTER, REG		FACILITY TYPE:	741
ADDRESS:	350 CALLOWAY DR		TELEPHONE:	(661) 587-0221
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93312
CAPACITY:	376	CENSUS: 203	DATE:	12/20/2021
		UNANNOUNCED	TIME BEGAN:	12:06 PM
MET WITH:	Administrator, Reg Webster		TIME COMPLETED:	12:54 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Questionable Death

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Darius Williams conducted an unannounced complaint visit to deliver findings. LPA Williams met with Administrator Reg Webster and discussed the purpose of the visit.

The Department has investigated the allegationregarding a questionable death.

Based on record review, Resident 1 passed due to an illness. 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.

An exit interview was conducted and a copy of this report was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2021 and conducted by Evaluator Darius Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20210907082850

FACILITY NAME:	BROOKDALE RIVERWALK		FACILITY NUMBER:	157203395
ADMINISTRATOR:	WEBSTER, REG		FACILITY TYPE:	741
ADDRESS:	350 CALLOWAY DR		TELEPHONE:	(661) 587-0221
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93312
CAPACITY:	376	CENSUS: 203	DATE:	12/20/2021
		UNANNOUNCED	TIME BEGAN:	12:06 PM
MET WITH:	Administrator, Reg Webster		TIME COMPLETED:	12:54 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff mismanaged residents medication

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Darius Williams conducted an unannounced complaint visit to deliver findings. LPA Williams met with Administrator Reg Webster and discussed the purpose of the visit.

The Department has investigated the allegation regarding staff mismanaged residents medication.

According to R1’s physician report dated 11/16/2020, R1 was not able to administer own medications or store their own medications.

According to interviews and record review, the facility released medication to R1, for a trip out of state, with out consulting R1’s physician.

*Continued on LIC9099C*

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 24-AS-20210907082850

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BROOKDALE RIVERWALK	FACILITY NUMBER: 157203395
	VISIT DATE: 12/20/2021

NARRATIVE

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

Based on the Departments record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87464(f)(1) is being cited on the attached LIC 9099D.

Civil penalties are pending and currently under review. The details of the civil penalties will be outlined in a future report to the facility.

Administrator provided documentation of training with 10 staff, conducted on 10/30/2021, regarding medication release policy and medication administration. Additionally, Staff 1 no longer works at the facility.

LPA Williams reviewed LIC 9099D with Administrator.

An exit interview was conducted, a copy of this report was provided, and appeal rights were provided.

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 24-AS-20210907082850

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BROOKDALE RIVERWALK	FACILITY NUMBER: 157203395
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/21/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services; (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met evident by:	1 2 3 4 5 6 7	Staff 1 no longer works at the facility. Administrator provided documentation of training conducted with 10 staff on, 10/30/2021, regarding medication release policy and medication administration. Plan of correction has been cleared.
	8 9 10 11 12 13 14	Based on interview and record review, the Licensee did not ensure staff contacted a physician prior to releasing medication to R1, which poses an immedite health and safety risk to person's in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4