197606945-12-17-2021-28-AS-LHIS-CGXJZY-20220803073013

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606945
Report Date: 12/17/2021
Date Signed: 12/17/2021 02:23:48 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/03/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211203142454

FACILITY NAME:	BROOKDALE CENTRAL WHITTIER		FACILITY NUMBER:	197606945
ADMINISTRATOR:	BARBARA TYLER		FACILITY TYPE:	740
ADDRESS:	8101 S PAINTER AVE		TELEPHONE:	(562) 698-0596
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90602
CAPACITY:	92	CENSUS: 67	DATE:	12/17/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Barbara Tyler, Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff failed to follow authorized representative's directive to reject flu shot administration.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subequent complaint visit to deliver findings on the above allegations. The purpose of the visit was discussed with Executive Director Barbara Tyler.

The investigation consisted of the following: On 12/10/2021, LPA reviewed document records and interviewed residents (R2- R9) and staff (S1- S7). Resident (R1) no longer resides at the facility and was not interviewed. Former resident (R1's) Authorized Representative was interviewed telephonically. Resident (R1's) documents [Face Sheet, Preplacement Appraisal Information, Physician Reports, Vaccine shot confirmation, flu shot authorization, Admission Agreement ("Residency Agreement'), Personal Solutions Agreement, Rate Disclosure Sheet, billing invoice information, incident report dated 10/27/21, staff roster, and resident roster] were reviewed and obtained. Resident (R10) was interviewed today.

See LIC 9099C for report continuation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

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-20211203142454

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE CENTRAL WHITTIER	FACILITY NUMBER: 197606945
	VISIT DATE: 12/17/2021

NARRATIVE

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Allegation: "Staff failed to follow authorized representative's directive to reject flu shot administration." Based on document review and interviews conducted the findings indicate that on 10/5/201 former resident (R1) was administered a flu shot at the facility by CVS pharmacy. It is alleged that authorized representative communicated to facility staff in advance that R1 has never received a flu shot; therefore chose to reject the flu shot, but agreed to receiving the COVID-19 booster shot. Resident (R1) has limited English language proficiency, and attempted to communicate to staff that it was rejecting the flu shot. According to interviews, staff informed R1 that the vaccine the resident was going to receive was the COVID-19 booster shot. Prior to the COVID-19 booster shot administration it was discovered R1 was still not eligible for the booster shot since it had not been at least 6 months from the 2nd COVID-19 vaccine dose.

Resident (R1) signed the flu shot consent thinking the consent was for the COVID-19 booster shot. Resident (R1) does not have a Power of Attorney. Therefore, the facility did not contact the authorized representative regarding vaccine consent. It is alleged that resident (R1) has cognitive impairment due to past health history and current health diagnosis. However, the Physician's Report does not indicate any Mild Cognitive Impairment or Dementia. A total of nine (9) residents were interviewed and all stated the flu shot was administered with their consent. Staff stated that residents and/or their authorized representative signed in advance the vaccine consent forms. Staff stated that on the date the flu shots were administered R1 willingly accepted the flu shot vaccine, after it was notified that there were extra flu shots available. A copy of the flu shot consent form signed by resident (R1) was obtained.

Based on interviews conducted and record reviewed there is insufficient information to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview conducted with Executive Director Barbara Tyler. A copy of the report was provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC9099 (FAS) - (06/04)

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