197606301-8-25-2023-28-AS-DSIS-CVGT96-20230908143126

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606301
Report Date: 08/25/2023
Date Signed: 08/25/2023 02:44:05 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
09/28/2022 and conducted by Evaluator Erik Zaragoza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220928101305

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:	08/25/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Mia Nakamatzu - Business Office Manager		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident sustained fall due to lack of supervision
Staff did not answer resident's call button in a timely manner
Resident did not receive hot meals

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erik Zaragoza conducted a follow up complaint investigation regarding the allegations listed above. LPA met with Mia Nakamatzu Business Office Manager of the facility and explained the reason for the visit. Administrator Logan Harrison arrived shortly thereafter.

The investigation revealed the following: during the initial visit conducted on 08/03/2022, LPA Joe Katrdzyhyan interviewed the Administrator, four (4) staff members, five (5) residents, and also obtained copies of Resident #1's (R1) Unusual incident/injury reports, Physician Report, Personal Service Plan, DIscharge Report, Residents/Staff Roster, and Facility Progress notes. During today's visit, LPA Zaragoza reviewed these documents and also obtained an updated Staff and Resident Roster list. LPA Zaragoza also interviewed Staff #1 - 6 (S1 - S6), and also Residents #2 - 9 (R2 - R9). LPA attempted to interview R1, however R1 no longer lives in the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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 3

Control Number 28-AS-20220928101305

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: 08/25/2023

NARRATIVE

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The investigation revealed the following: in regards to the allegation "Resident sustained fall due to lack of supervision", it is alleged that R1 had sustained a fall while living at the facility due to a lack of care and supervision. During interviews with the residents, four (4) out of eight (8) stated that they have either fallen themselves personally or have heard of other residents falling in the facility, but that it was not due to lack of supervision. R3 stated that when they fell that the facility quickly called paramedics to assist R3, and R6 along with R9 have heard of residents sustaining falls within the facility but also that they were promptly assisted. In interviews with Staff five (5) out of six (6) could not corroborate the allegation that residents have fallen due to lack of care and supervision. S3 and S5 explained that while falls have occurred within the facility, staff have never been negligent in assisting the residents when they do fall.

In regards to the allegation "Staff do not answer call button in a timely manner", it is alleged by R1's family that they attempted to call staff to her room during the night shift and that it look 30 - 42 minutes for a caregiver to come to R1's room to provide assistance. During interviews with the residents of the facility, none of them could corroborate the allegation that the staff at the facility do not answer their call light requests in a timely manner. R6 and R8 explained that they usually get assistance when they use their call lights quickly within five (5) to ten (10) minutes, and if there ever is a delay it is because the caregivers are busy assisting other residents, and that it is never because they are neglecting to answer the call lights. None of the staff members corroborated this allegation, and S4 explained that once the call light signal request is sent by a resident, their computer system is immediately notified and all caregivers and Medical Technicians are paged directly once it is received informing them of the name of the resident and where they are located within the facility. LPA tested the call light system in one of the resident rooms, #124, and was able to see that the signal was related to their computer system immediately, and observed the pagers emitting their sound signal to the caregivers, which allowed them to respond to the room in approximately three (3) minutes.

In regards to the allegation that "Resident did not receive hot meals", it is alleged that whenever R1 asked for food to be delivered to their room, it always arrived cold. During interviews with residents, seven (7) out of eight (8) could not corroborate the allegation that they have been served cold food. Most explained that they have never been served cold food, and R7 explained that if food is ever served cold the staff have fixed it by either heating up the food or providing a new plate of food. During interviews with staff, none of them corroborated the allegation that food has been served cold to the residents.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220928101305

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: 08/25/2023

NARRATIVE

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LPA interviewed S2 who used to work in the kitchen area along with S6 who currently works as part of the kitchen staff, and when asked how they ensure that food is kept warm when delivering it to the rooms of the residents, they explained that once they know the residents that are requesting food to be delivered to their rooms, the kitchen staff make sure they are the first trays that are sent out so that they are still warm by the time they get delivered to the resident's room. Additionally both S2 and S6 stated that they wrap the warm food tightly in saran wrap and also cover the food as well so that it stays warm for as long as possible.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations 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.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

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