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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204701
Report Date: 07/07/2021
Date Signed: 07/07/2021 04:01:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 WALNUTFACILITY NUMBER:
198204701
ADMINISTRATOR:MATSUMOTO, CHRISTINAFACILITY TYPE:
740
ADDRESS:19850 E COLIMA RDTELEPHONE:
(909) 595-5030
CITY:WALNUTSTATE: CAZIP CODE:
91789
CAPACITY:120CENSUS: 52DATE:
07/07/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Christina Matsumoto, administratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Spencer conducted a case management visit to follow-up on an incident report dated 6/28/21. LPA Spencer was met by administrator Christina Matsumoto and explained the purpose of today's visit.

The incident report was regarding 52 missing Norco tablets belonging to resident #1 (R1) and a subsequent police visit regarding the missing medication. LPA Spencer interviewed the administrator, R1, and R1's responsible party (F1). LPA Spencer attempted to interview R1's physician but was unable to be reached. LPA Spencer collected copies of R1's face sheet, care plan, physician's report, medication self-administration review, police report, and in-service training log.

LPA Spencer reviewed R1's physician's report, medication self-administration review, and care plan showing that R1 is able to administer, order, and store own medications. The police incident report from 6/24/21 stated that R1 did not want to further investigate possible theft but believes that they were either stolen or misplaced. Police report also stated a possible medication misuse by R1. LPA reviewed the in-service training logs for the training conducted today, 7/7/21, in which staff were trained on theft and loss policies and resident rights.

The administrator stated that R1 is able to administer own medications but is required to keep them locked in the room to prevent theft. R1 has a private room but staff have access to the room. R1 and F1 stated that there have been pills missing in the last two months and believe staff may have stolen it. R1 now lock them up and tracks daily usage. Administrator stated that a nurse has been assigned to help R1 track the usage of the Norco pills. Administrator stated that in-service training was conducted but does not believe the pills were stolen as there have been prior theft incidences reported.

There were no deficiencies cited at this time. An exit interview was conducted with administrator and a copy of the report was emailed.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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