306002915-6-12-2024-22-AS-SSAS-D6924N-20240614170409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002915
Report Date: 06/12/2024
Date Signed: 06/12/2024 01:01:19 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
03/15/2024 and conducted by Evaluator Alvaro Ramirez Jr.

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240315145811

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: 108	DATE:	06/12/2024
		UNANNOUNCED	TIME BEGAN:	12:21 PM
MET WITH:	Troy Byington-Administrator		TIME COMPLETED:	01:21 PM

ALLEGATION(S):

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Staff did not provide resident's medical records to authorized representative

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on March 15, 2024. LPA Ramirez was allowed entry into the facility and met with Administrator (AD) Troy Byington. LPA explained the purpose of the visit.

This Department has investigated the complaint alleging that staff did not provide resident's medical records to authorized representative. Resident 1 (R1) was admitted to the facility on April 17, 2020. Documents reviewed included the email request for R1’ medical records dated February 15, 2024. The email request was received by the facility AD on February 15, 2024. During the course of the interviews with staff, Staff 1 (S1) reported that resident medical requests are processed by the AD. During interviews with witnesses, Witness 1 (W1) reported that as of April 04, 2024 the records had not been received yet. During the course of the interviews AD reported that all requested documents were sent to the requestor on April 5, 2024.

CONTINUED ON LIC9099-C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

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 22-AS-20240315145811

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BROOKDALE ANAHEIM	FACILITY NUMBER: 306002915
	VISIT DATE: 06/12/2024

NARRATIVE

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On May 1, 2024 LPA received an email from the requestor stating that they had received over 1,000 pages of R1’s records. Therefore, the requestor received R1's medical records approximately one and a half months after their email request.

Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: staff did not provide resident's medical records to authorized representative is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

LPA Ramirez conducted an exit interview with AD Byington and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240315145811

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BROOKDALE ANAHEIM	FACILITY NUMBER: 306002915
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/12/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/12/2024 Section Cited CCR 87506(c)(1)	1 2 3 4 5 6 7	(c)All information and records obtained from or regarding residents shall be confidential. (1)...The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.	1 2 3 4 5 6 7	Per AD on April 05, 2024 R1's medical records were mailed to the requestor.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: the facility provided the medical records approximately one and a half months after the request was received. This poses a potential risk to persons 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: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC9099 (FAS) - (06/04)

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