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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606301
Report Date: 08/31/2023
Date Signed: 08/31/2023 04:16:33 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
04/07/2022 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220407091359
FACILITY NAME:BROOKDALE MONROVIAFACILITY NUMBER:
197606301
ADMINISTRATOR:BALBIN, RALPHFACILITY TYPE:
740
ADDRESS:201 E FOOTHILL BLVDTELEPHONE:
(626) 301-0204
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:75CENSUS: 51DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Logan Harrison - AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff is not properly trained.
Facility has pests.
Resident's personal items poses a hazard for resident in care.
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 the Administrator of the facility Logan Harrison and explained the reason for the visit.

The investigation consisted of the following: during the initial visit conducted on 04/14/2022, LPA Joe Katrdzyhyan interviewed two (2) Staff Members, three (3) Residents, toured the room of Resident #1 (R1), and obtained copies of the Course Completion History, Training Hours and Work Schedule for Staff #1 (S1). During today's visit, LPA Zaragoza reviewed these documents and also obtained an updated Staff and Resident Roster list, Physician Reports for Residents #3 - 5 (R3 - R5) along with Resident #8 (R8), and also obtained records of trainings for Staff #3 - 7 (S3 - S7). LPA Zaragoza also interviewed S2 - S7, and also Residents #2 - 8 (R2 - R8). LPA attempted to interview R1, however R1 no longer lives in the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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 6
Control Number 28-AS-20220407091359
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: 08/31/2023
NARRATIVE
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The investigation revealed the following: in regards to the allegation "Staff is not properly trained", it is alleged that staff at the facility are not trained properly and do not have the time necessary to complete the tasks outlined in their training materials. During interviews with the staff along with review of the staff training records, none of the staff members corroborated the allegation that they are not properly trained. S3 - S5 explained that they are all required to perform initial when hired which is facility by computer courses, and afterwards receive in-person known as "Shadowing" in which they work in conjunction with other seasoned staff before they are allowed to work independently. S2-S6 all indicated that annual training is conducated as well to ensure they retain knowledge of proper protocols and procedures. Record reviews of the staff training revealed that they had updated training on CPR along with completed online courses in medication management, policies, and techniques on caregiving as well.

In regards to the allegation "Facility has pests", it is alleged that R1's room contained pests including bugs that crawled over R1's body in bed. During interviews with the residents, none of them were able to corroborate the allegation that there has been a problem with pests within the facility. R2, R7, and R8 stated that occasionally a fly, gnat, or small insect will enter the facility if a door is left open however it has not been a major problem within the facility. During interviews with the staff members of the facility, none of them corroborated the allegation that pests have been an issue in the past. S2, S4, and S5 all claimed that if there was any evidence of an issue with pests at the facility, they work with Ecolab for pest control services to address any potential problem.

In regards to the allegation that "Resident's personal items poses a hazard for resident in care", it is alleged that R1 had been hoarding an excessive amount of personal items in their room which was causing a fire hazard at the facility. During interviews with the residents, seven (7) out of eight (8) residents have never heard of residents hoarding items within their rooms. R2 - R7 all claimed that they have witnessed any potential hazards within the facility while living here, and that they believe it is safe living at the facility. During interviews with the staff, none of them corroborated the allegation that residents have been living in hoarding conditions in their rooms. S3 stated that if a residents room became cluttered to the extent that it became a fire hazard, the facility would ensure to assist the resident in removing unnecessary items to avoid any potential hazards. LPA toured five (5) different resident rooms and none of them were observed to have excessive amounts of clutter that would pose a fire hazard.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20220407091359
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: 08/31/2023
NARRATIVE
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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 above allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
04/07/2022 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220407091359

FACILITY NAME:BROOKDALE MONROVIAFACILITY NUMBER:
197606301
ADMINISTRATOR:BALBIN, RALPHFACILITY TYPE:
740
ADDRESS:201 E FOOTHILL BLVDTELEPHONE:
(626) 301-0204
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:75CENSUS: 51DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Logan Harrison - AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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2
3
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5
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9
Glucose testing is being administered by med techs and not an appropriately skilled professional.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted a follow up complaint investigation regarding the allegation listed above. LPA met with the Administrator of the facility Logan Harrison and explained the reason for the visit.

The investigation consisted of the following: during the initial visit conducted on 04/14/2022, LPA Joe Katrdzyhyan interviewed two (2) Staff Members, three (3) Residents, toured the room of Resident #1 (R1), and obtained copies of the Course Completion History, Training Hours and Work Schedule for Staff #1 (S1). During today's visit, LPA Zaragoza reviewed these documents and also obtained an updated Staff and Resident Roster list, Physician Reports for Residents #3 - 5 (R3 - R5) along with Resident #8 (R8), and also obtained records of trainings for Staff #3 - 7 (S3 - S7). LPA Zaragoza also interviewed S2 - S7, and also Residents #2 - 8 (R2 - R8). LPA attempted to interview R1, however R1 no longer lives in the facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20220407091359
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: 08/31/2023
NARRATIVE
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Regarding the allegation "Glucose testing is being administered by Med Techs and not an appropriately skilled professional", it is alleged that only nurses are supposed to be conducting blood sugar testing for diabetic residents, however it is alleged that Med Techs were conducting the testing as well each were doing the tests differently. During interviews with residents, one (1) out of eight (8) residents interviewed corroborated the allegation. R3 explained that S7 has been conducting the blood sugar testing, including pricking her finger with the lancet, in order to get a reading on her blood sugar levels. During an interview with S7, S7 explained that they do prick the finger of R3 in order to draw blood so that they can get a reading of R3's blood sugar levels. Record review of R3's physician report, dated 5/27/2023, revealed that R3 is not able to perform their own glucose testing. According to Title 22 Regulations, 87101(a)(10), by definition an appropriately skilled professional is "an individual that has training and is licensed to perform the necessary medical procedures prescribed by a physician. This includes but is not limited to the following: Registered Nurse (RN), Licensed Vocational Nurse (LVN), Physical Therapist (PT), Occupational Therapist (OT) and Respiratory Therapist (RT). These professionals may include, but are not limited to, those persons employed by a home health agency, the resident, or facilities and who are currently licensed in California."

Based on LPAs interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegation, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 3 are being cited on the attached LIC9099D.

Exit interview held and a copy of the report and appeal rights was provided to the administrator Logan Harrison.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20220407091359
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2023
Section Cited
CCR
87628(a)
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87268 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing (...) or has it administered by an appropriately skilled professional.
The requirement is not met as evidenced by:
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Administrator shall ensure that only appropriate skilled professionals administer medicaiton through injection or assist residents with glucose testing while in care. During record review and interviews, it was determined that R3 is not able to test her own glucose levels.
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Based on interview and record review conducted with residents and staff, LPA determined that R3 is getting their blood sugar level tested by S7. Additionally, R3's physician report indicates that R3 cannot test their own glucose levels, which poses an immediate risk for clients in care.
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(Cont.) Additionally it was revelaed that S7 does the glucose testing for R1 even though theyare not a skilled professional. Administrator to submit a written plan indicating how facility will meet regulation 87628 moving forward.
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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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6