306002915-12-18-2023-22-AS-SSAS-CZYU2F-20240130141153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002915
Report Date: 12/18/2023
Date Signed: 12/18/2023 02:59:56 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/17/2021 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210517141739

FACILITY NAME:	BROOKDALE ANAHEIM		FACILITY NUMBER:	306002915
ADMINISTRATOR:	TROY BYINGTON		FACILITY TYPE:	740
ADDRESS:	200 N DALE ST		TELEPHONE:	(714) 761-5771
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	140	CENSUS: 110	DATE:	12/18/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Troy Byington		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Resident sustained pressure injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings for the complaint investigation for the allegation listed above. LPA met with Executive Director Troy Byington and explained the reason for the visit. The investigation into the allegation revealed the following. Resident 1 (R1) returned from the skilled nursing facility on or around 4/14/2021. R1 was receiving visits from Home Health and Physical Therapy after their return to the facility. It was reported that R1 sustained a pressure injury while in care. A review of facility records shows R1 was diagnosed with a stage 2 pressure injury on 5/13/2021 by a medical professional and it was healed by 5/22/2021. 4 out of 4 Staff interviewed reported that R1 likes to be in a reclining chair all day and refuses to change positions or to be in their bed or any other chair during the day. R1’s family member reported that R1 likes to be in the reclining chair to watch TV and doesn’t want to be in bed except to sleep. Staff reported that they reposition R1 in the reclining chair when R1 allows them. R1 has passed away and was not interviewed. The Responsible Party for R1 would not respond to requests to be interviewed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

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 5

Control Number 22-AS-20210517141739

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BROOKDALE ANAHEIM	FACILITY NUMBER: 306002915
	VISIT DATE: 12/18/2023

NARRATIVE

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R1 has a history of pressure injuries as noted in their physician’s report dated 4/13/21. R1 did sustain a pressure injury while residing at the facility that was diagnosed, treated, and healed. There is no evidence to prove the pressure injury was caused by the facility staff or through neglect.

Based on the evidence gathered the allegation, resident sustained pressure injury while in care is deemed unsubstantiated, although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of the report provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/17/2021 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210517141739

FACILITY NAME:	BROOKDALE ANAHEIM		FACILITY NUMBER:	306002915
ADMINISTRATOR:	TROY BYINGTON		FACILITY TYPE:	740
ADDRESS:	200 N DALE ST		TELEPHONE:	(714) 761-5771
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	140	CENSUS: 110	DATE:	12/18/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Troy Byington		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff failed to meet resident’s hygiene needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings for the complaint investigation for the allegation listed above. LPA met with Executive Director Troy Byington and explained the reason for the visit. The investigation into the allegation, staff failed to meet the resident’s hygiene needs, revealed the following. It was alleged that Resident 1 (R1) was left in soiled diapers and not changed timely. 4 out of 4 staff interviewed reported that R1 is checked regularly and changed in a timely manner when needed or when requested by R1. R1’s family member reported that when they have visited R1 on numerous occasions the room smelled of urine because R1 was not assisted with incontinence care in a timely manner. R1’s family member reported that on 5/16/2021 R1 was left in their soiled diaper for a long period of time because they observed R1 had feces under a bandage for a wound on their buttock. This would not be the case if it had just happened, because then it would only be on the outside of the bandage. This report was verified with visual documentation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 22-AS-20210517141739

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BROOKDALE ANAHEIM	FACILITY NUMBER: 306002915
	VISIT DATE: 12/18/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the facility along with appeal rights.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 22-AS-20210517141739

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BROOKDALE ANAHEIM	FACILITY NUMBER: 306002915
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/19/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This regulation was not met as evidence by:	1 2 3 4 5 6 7	Licensee to ensure all care staff are trained on CCR 87464(f)(1). Proof of training to be forwarded to LPA by due date.
	8 9 10 11 12 13 14	The licensee failed to ensure that the facility provided care and supervision as defined. Based on documentation and information provided through interviews, R1 was left in a soiled diaper for a long period of time as evidenced by the fact that R1 had feces under a bandage for a wound on their buttock. This poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5