197606945-12-17-2021-28-AS-LHIS-CGXJZX-20220803073012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606945
Report Date: 12/17/2021
Date Signed: 12/17/2021 02:25:24 PM

Substantiated

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 did not inform authorized representative of resident's fall resulting in an injury.
Staff would not itemize the resident's bill.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subequent complaint visit to deliver findings on the above allegation. 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.

Substantiated

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)

Page: 1 of 4

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 did not inform authorized representative of resident's fall resulting in an injury." Based on record review and interviews conducted the findings indicate that on October 10, 2021 former resident (R1) sustained a fall inside the resident's room resulting in bruising and scrapes to the left knee. Picture evidence was obtained. According to staff, R1 had a total of two (2) falls dated [10/10/21 & 10/27/21]. The fall dated 10/10/21 was not reported to Community Care Licensing (CCL). In addition, the authorized representative did not notification via phone call because the phone number listed on R1's face sheet was incorrect, and staff were not able to decipher the exact numbers listed on the emergency contact information document. Resident (R1's) authorized representative became aware of the 10/10/21 fall during a visit shortly after the incident. The authorized representative and med-tech staff (S5) discovered the phone number listed was incorrect. Therefore, confirmed the authorized representative did not receive phone call notification of the fall injury.

The second fall dated 10/27/21 was reported to CCL and authorized representative. Caregiver staff notified med-tech staff (S3) who called 911 Emergency. Resident (R1) was transported to Whittier Presbyterian Hospital for evaluation. The resident returned back to the facility the same day.

Allegation: "Staff would not itemize the resident's bill." Based on record review and interviews conducted the findings indicate that on September 23, 2021 former resident (R1) docu-signed the "Residency Agreement" that includes a price schedule for services and outlines charges. A "Community Fee of $2,500" and "Basic Service Rate of $1,760" was noted. No additional charges/fees were observed under the "Personal Service Rate" line item; which would include additional care services like bathing and/or incontinence care assistance. It is alleged that resident (R1's) authorized representative received an invoice bill statement with charges that were not agreed upon or authorized. Resident (R1's) family called the facilities several times requesting an explanation of additional charges and a copy of an itemized bill, but did not receive calls back. The itemized bill was provided over 1 week later until the authorized representative went in person to the facility. However, an explanation of the charges was not provided at the time of the visit. The itemized bill listed additional "Personal Service Rate" charges in the amounts of [Showering $128.00 and Bathroom Assist $769.00] totaling an additional $897.00 per month in fees in addition to rent fees.

See LIC 9099 for report continuation.

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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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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According to staff interviews, resident (R1's) family agreed to the shared room rate and a "Personal Service Rate" fee of $128 dollars for shower/bathing assistance. However, the Residency Agreement obtained did not list additional "Personal Service Rate" fees. The Executive Director, Health and Wellness Director, Sales Manager, Business Office Manager were interviewed and all acknowledged that the Residency Agreement does not list any additional charges aside from rent fees. Former resident (R1) no longer resides at the facility and was not interviewed; only R1's authorized representative was interviewed. Supportive document evidence was obtained.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Health and Safety Code Chapter 3.2 Residential Care Facilities for the Elderly, Article 02.5 Resident's Bill of Rights & Title 22, Division 6 Chapter 8 Article 04. Operating Requirements.

An exit interview was conducted with Executive Director Barbara Tyler. A copy of the report an appeal rights were 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)

Page: 3 of 4

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/24/2021 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified ... below. Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a	1 2 3 4 5 6 7	Administrator shall review Title 22 Regulations 87211 and submit a written plan on steps the facility will take in the future related to any incident which threatens the welfare, safety or health of any resident. In addition, staff shall receive in-service training on reporting requirements and documentation.
	8 9 10 11 12 13 14	resident by staff or other residents, or unexplained absence of any resident. This requirement was not met by evidence of: On 10/10/21 R1 sustained a fall resulting in scrapes and bruising to the kneee, which was not reported to authorized representive or Community Care Licensing. This poses a potential health and safety risk.	8 9 10 11 12 13 14
Type B 12/24/2021 Section Cited HSC 1569.269(a)(21)	1 2 3 4 5 6 7	Enumerated rights; severability. Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies.	1 2 3 4 5 6 7	Administrator shall develop and implement a policy and procedure to include California Health and Satefy Code regulation, 1569.269, as to how this facility will handle requests for residents records in a timely manner. Additionally, Administrator shall train the designated personnel on this policy and procedure and include proof of this training to
	8 9 10 11 12 13 14	This requirement was not met by evidence of: Based on interview and record review resident (R1's) itemized bill records were not provided to authorized representative within two business days. Facility provided a copy of the itemized bill until Nov 4, approximately 2 weeks after phone request was made. This poses a potential health and safety risk.	8 9 10 11 12 13 14	LPA by POC due date.

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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC9099 (FAS) - (06/04)

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