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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204701
Report Date: 04/15/2021
Date Signed: 04/15/2021 05:12:34 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
09/11/2020 and conducted by Evaluator LaJean Nicole Spencer
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200911140639
FACILITY NAME:BROOKDALE WALNUTFACILITY NUMBER:
198204701
ADMINISTRATOR:MATSUMOTO, CHRISTINAFACILITY TYPE:
740
ADDRESS:19850 E COLIMA RDTELEPHONE:
(909) 595-5030
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY:120CENSUS: 64DATE:
04/15/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Christina MatsumotoTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not notify residents authorized representative about residents decline in health
Staff did not safeguard residents belongings
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Christina Matsumoto, the facility administrator.

The initial 10-day complaint investigation was conducted on 9/17/20 which included a tour of the physical plant and interviews with administrator and staff #1-3 (S1-S3). During the course of the investigation, LPA also interviewed staff #4-7 (S4-S7), residents #1-7 (R1-R7), and the nurse practitioner for R1. LPA Spencer received and reviewed the staff roster, resident roster, and the facility's theft and loss policy. For R1, LPA also reviewed: resident face sheet, inventory list of valuables, Needs & Services plan, re-appraisal/increase letter, caregivers notes (June-August 2020), nurse practitioner (NP) notes, and physician's reports.
***See LIC9099C for continuation of narrative.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
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 3
Control Number 28-AS-20200911140639
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: 04/15/2021
NARRATIVE
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The investigation revealed the following:
Staff did not notify residents authorized representative about residents decline in health
It was alleged that the facility was not updating R1's responsible party (RP) about her decline in health and change in condition, specifically regarding loss of appetite and weight loss. During the physical plant tour of the med tech room, LPA observed the monthly weight charts for R1 which showed that R1 weighed 168 lbs on 8/26/20 and had a stable weight for the past year. R1 was moved to a new board and care in late August. In an interview, R1's nurse practitioner (NP) stated that R1's weight loss took place in September 2020 when R1 moved to a new board and care and her weight went down to 150 lbs. A review of the NP notes from 9/14/20 state that R1 was placed on hospice. NP stated that she was informed about a slight decrease in R1's appetite about 3 months prior to her move. NP stated that the resident was declining in overall health including with memory, incontinence, and needing greater assistance with activities of daily living. She stated that all of these changes were communicated with RP by both her and Brookdale staff when they recommended a higher level of care and sent the re-appraisal/increase letter. Interviews with the administrator and S1 revealed that the facility recommended a higher level of care due R1's overall decline in health. S1 stated that while at Brookdale there was not a drastic decline in R1's appetite/weight but in needing greater assistance with daily living. S1-S7 also stated that R1 was a good eater, but noticed that she didn't eat as much about 1-2 a week. Staff stated that they would uncover the food or sit with R1 to ensure that she ate. R1-R3 stated that they didn't notice a change in R1's weight while living at Brookdale, while R4-R7 did not remember the resident. LPA reviewed the caregivers notes and observed there were two notes in late August regarding lack of appetite but the rest of the notes were regarding assistance with using the restroom, dressing, and accidents in diapers. A review of the NP notes from 8/24/20 also confirm problems with frequent urination and incontinence, memory impairment, and decreased appetite. The physician's report from 2019 and 2020 reveal an overall decline in health status. The reappraisal/increase letter corroborates these changes in health and recommends a higher level of care. The administrator stated that RP was informed about these changes. However, due to increased costs, RP decided to move R1 to a different facility.
Staff did not safeguard residents belongings
Upon moving out, RP stated that R1 was missing a ring and a blanket and that staff had partially helped R1 pack even though she requested to do it herself. The administrator stated that she was not aware of staff helping R1 pack and that usually resident family members do this. S1 stated that it is common practice to assist residents with packing and that caregivers in fact assisted R1 with packing prior to moving out. The Administrator, S1, S4, and S5 stated that they were made aware of the missing items, while S2, S3, S6 and S7 stated that they were not aware of missing items. ***Narrative continued on 9099-C.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20200911140639
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: 04/15/2021
NARRATIVE
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S5 stated that she and other staff assisted with packing R1's items, however they only packed clothes and shoes. All staff stated that they had never personally observed the missing items. R1 stated that she possibly recalls having the missing items but was not sure what happened to them. R2-R3 were not aware of the items while R4-R7 did not remember the resident. S1 and R2 stated that R1 sometimes left her door open because she did not like it closed. RP stated that the last time she had seen the items were in February 2020. Upon review of the facilities theft and loss policy, it states that the facility maintains an inventory of personal property identified by the resident upon admission using the LIC621 form, which is signed by the resident or their responsible party. Any property added to the inventory list must be signed for by resident or witnessed by authorized member of the facility. In addition, if an item is reported missing, there will be an effort to search the resident rooms and common areas and staff on duty will be questioned regarding the missing items. A review of the signed LIC621 for R1 reveals that there were no items listed on the inventory list upon admission nor any items added at a later date.

Based upon physical plant observations, interviews conducted, and documents reviewed, the findings indicate although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated.

A telephonic exit interview was conducted with administrator Christina Matsumoto. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3