197606301-3-14-2023-28-AS-RORN-CTVUYJ-20230719160000

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606301
Report Date: 03/14/2023
Date Signed: 03/14/2023 03:31:32 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/10/2023 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230310090010

FACILITY NAME:	BROOKDALE MONROVIA		FACILITY NUMBER:	197606301
ADMINISTRATOR:	BALBIN, RALPH		FACILITY TYPE:	740
ADDRESS:	201 E FOOTHILL BLVD		TELEPHONE:	(626) 301-0204
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY:	75	CENSUS: 51	DATE:	03/14/2023
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Danny Vera		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility failed to re-filled Prescription for resident
Facility fail to inform responsible party prescription was not filled

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced initial 10 days complaint visit and LPA met with Business Office Manager Mia Nakamatzu who allowed the entry of the facility and explained the reason of the visit. Shortly after, the Executive Director Danny Vera arrived and assisted with the visit.

The investigation consisted of the following: On today's visit, LPA interviewed Executive Director, three staff (S1-S3)in the facility and one staff via telephone and six residents (R2-R7) in the facility and obtained Resident#1 (R1) documents including face sheet, admission agreement, Medication Admin Adult Report (Jan to March, 2023), Physician Report dated on 05/06/2021, Personal Service Plan dated on 06/25/2022, Progress Notes (June 2022 to Feb 2023) and LPA reviewed three residents' medication in the facility.

(See LIC 9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230310090010

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE MONROVIA	FACILITY NUMBER: 197606301
	VISIT DATE: 03/14/2023

NARRATIVE

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The investigation revealed of the following: Allegation#1 "Facility failed to re-filled Prescription for resident" LPA interviewed six residents and all denied the allegation and reported they never missed any medication in the facility and staff never forgot to refill their medication. LPA interviewed staff and reported they usually would assist resident to refill the medication when they have about 7 days medication left , they would either call the pharmacy to refill the prescription or family/responsible party about residents' medication are running low and request them to bring the medication to the facility . If family did not answer, they would leave a message and continue to call the responsible party everyday. The staff also stated that if it is an emergency and they would call the facility pharmacy to refill the medication and the pharmacy can deliver the medication within the same day. The staff stated that R1's routine medication which is through the facility pharmacy Omnicare and R1's PRN medication (Carbidopa Leveodopa) is through Kaiser which R1's family handle it. R1's family would assist R1 to refill the medication/prescription and deliver the medication to the facility. The facility has no interaction with Kaiser. Facility staff would remind family to refill R1's prescription when the medication is running low. LPA also inspected 3 residents medication and all residents medication are updated and current.

Allegation#2 "Facility fail to inform responsible party prescription was not filled" LPA interviewed residents and all denied the allegation and reported the facility is very good at contacting their family members or responsible party for any related medical issues. LPA interviewed staff and reported they did contact R1's family/daughter when R1's medication was running low or when the medication is ready to pick up. Staff did leave a message to R1's family. LPA also reviewed the facility nursing department communication log /progress notes for R1 and it indicated that nurse did remind R1's family to pick up R1's PRN medication and left message to R1's family that R1's PRN medication was ready to pick up.

Based on the interviewed conducted with residents and staff and record reviewed, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted and a copy of this report was provided to the Executive Director Danny Vera

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC9099 (FAS) - (06/04)

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