197802426-9-15-2021-28-AS-LHIS-C7XQML-20211019121743

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802426
Report Date: 09/15/2021
Date Signed: 09/15/2021 05:59:22 PM

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
04/06/2021 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210406115343

FACILITY NAME:	BROOKDALE ALHAMBRA		FACILITY NUMBER:	197802426
ADMINISTRATOR:	WENTWORTH, NICOLE D		FACILITY TYPE:	740
ADDRESS:	1 E COMMONWEALTH AVE		TELEPHONE:	(626) 289-3871
CITY:	ALHAMBRA	STATE: CA	ZIP CODE:	91801
CAPACITY:	150	CENSUS: 67	DATE:	09/15/2021
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Tracey Holder, Executive Director		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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1. Staff is not assisting resident with incontinence needs.
2. Staff do not respond to call buttons in a timely manner.
3. Staff serves resident cold food.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit for the allegations listed above. LPA arrived unannounced and met with Tracey Holder, the Executive Director. The purpose of the visit was explained.

The investigation consisted of the following:
On 4/12/21, LPA Chan conducted the initial complaint investigation which consisted of interviews with the Administrator, 4 residents and 2 staff. LPA also received a copy of the Staff and Resident rosters and the week's menu. During today's visit, LPA held additional interviews with 3 staff and 5 residents.

The investigation revealed the following:
Allegation - Staff is not assisting resident with incontinence needs. It is alleged that Resident #1 (R1) is left in soiled diapers for extended periods of time. According to staff interviews, staff denied leaving R1 in soiled (LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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-20210406115343

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 ALHAMBRA	FACILITY NUMBER: 197802426
	VISIT DATE: 09/15/2021

NARRATIVE

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diapers. Per caregivers, they do their rounds every 2 hours and check/change the diapers of those with incontinence needs. They would change their diapers more often if needed. They also remind residents to press the call pendant for assistance. Other staff have not heard R1 or other residents being left in soiled diapers for long periods of time. LPA interviewed a total of 9 residents with those who need assistance with incontinence care and/or some assistance of daily living. 1 out of 9 residents indicated that staff does not change his/her diaper frequently and is left with having to be in soiled diaper for a long time. The rest stated that staff change their diapers as needed.

Allegation - Staff do not respond to call buttons in a timely manner. It is alleged that due to insufficient staffing, resident is left in soiled diapers for a extended periods of time. Based on information gathered, there are normally the following number of staff per shift who assist residents: Morning shift has 3 caregivers and a Med Tech; Afternoon Shift has 2 caregivers plus a Med Tech; and Evening (NOC) Shift has 2 caregivers plus a Med Tech. Staff interviewed stated they check on residents about every 2 hours and would change their diapers if needed. Staff interviewed denied leaving residents in soiled diapers for long periods of time. Staff stated they would assist residents as quickly as possible, but sometimes, it would take longer to respond to a resident's call when they are helping another resident. However, they indicated residents usually press the pendant for other reasons than to have their diapers changed. Med Techs stated they would also assist caregivers if they need to. LPA interviewed 9 residents and which 4 of them indicated sometimes it would take more than 30 minutes to respond to their calls and feel there is a shortage of caregivers. Based on interviews, there is insufficient evidence to corroborate this allegation.

Allegation - Staff serves residents cold food. According to interviews conducted with staff, the food are not served cold. During the closure of the dining room because of the Covid-19 pandemic, the residents had their meals delivered to their rooms and were wrapped in foil to maintain the heat. The residents now have the option to eat in their rooms or the dining room. Staff explained that they would deliver the hot meal to the resident's room and sometimes the resident would not eat their meals right away. When this happens, the food would get cold, not that the food is serve to them cold. LPA interviewed 9 residents in which 3 stated that their food is cold and need to be reheated in the microwave.

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.
An exit interview was conducted. A copy of this report and appeal rights were provided to the Executive Director.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC9099 (FAS) - (06/04)

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