198204701-12-2-2020-28-AS-MVAO-BXGNYU-20210121095318

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204701
Report Date: 12/01/2020
Date Signed: 12/02/2020 03:54:04 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
10/27/2020 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201027114202

FACILITY NAME:	BROOKDALE WALNUT		FACILITY NUMBER:	198204701
ADMINISTRATOR:	MATSUMOTO, CHRISTINA		FACILITY TYPE:	740
ADDRESS:	19850 E COLIMA RD		TELEPHONE:	(909) 595-5030
CITY:	WALNUT	STATE: CA	ZIP CODE:	91789
CAPACITY:	120	CENSUS: 71	DATE:	12/01/2020
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Christina Matsumoto		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Licensee did not provide food of good quality to residents in care

INVESTIGATION FINDINGS:

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The purpose of this report is to deliver the findings from the original complaint dated 10/27/2020.
Initial visit was conducted 11/02/2020 and the following was done:
Tour of the kitchen and food supply was conducted at 1:30 PM
Administrator was interviewed at 1:45 PM.
Staff 1 was interviewed at 2:00 PM.
Staff 2 was interviewed at 2:10 PM.
Residents 1-4 were interviewed from 2:10 PM to 2:35 PM.
Subsequent visit was conducted 11/17/2020 and the following was done:
At 10:50 AM to 11:50 AM Staff 1-3 were interviewed and Client 1 was interviewed.
Various documents to be submitted from Client 1's file.
In regards to the allegation Licensee did not provide food of good quality to residents in care, on initial visit conducted on 11/02/2020 tour of the kitchen and food supply and a well balanced supply of food was observed which included produce, vegetable, pork tenderloin, ham and chicken.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020

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-20201027114202

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 WALNUT	FACILITY NUMBER: 198204701
	VISIT DATE: 12/01/2020

NARRATIVE

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There were large supplies of frozen vegetables and fresh vegetables.
There were alot of fruits and cabbage and squash.
There were hot dogs, eggs and bacon.
LPA observed 4 loafs of bread with expiration date not expired listed as 11/05/2020 and fruit cocktail not expired listed as 11/23/2020.
All client's interviewed stated they had never received bread with mold on it and meat was never served not cooked properly.
Staff interviewed stated bread would never be given out with mold on it because the bread company comes twice a week and will replace old bread with new bread.
Staff also stated that Resident 1 will bring extra bread and food to their room and old food was observed during inspection by staff. One staff stated that Resident 1 had come to them with her concern and staff said bread was very hard and was not from that day and told that to Resident 1 and said Resident 1 could not answer what day it was from when asked.
It should also be noted that there is not a Staff that is a cook named David. There is a Maintenance man named David.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Hard copy was provided via email for signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020

LIC9099 (FAS) - (06/04)

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