306002954-8-3-2023-22-AS-SSAS-CUDQL6-20230804121524

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002954
Report Date: 08/03/2023
Date Signed: 08/03/2023 01:26:37 PM

Substantiated

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
12/20/2022 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221220140629

FACILITY NAME:	BROOKDALE IRVINE		FACILITY NUMBER:	306002954
ADMINISTRATOR:	CARRIE GALLOWAY		FACILITY TYPE:	740
ADDRESS:	10 MARQUETTE		TELEPHONE:	(949) 854-3766
CITY:	IRVINE	STATE: CA	ZIP CODE:	92612
CAPACITY:	155	CENSUS: 65	DATE:	08/03/2023
		UNANNOUNCED	TIME BEGAN:	11:01 AM
MET WITH:	Executive Director - Shannon Howell		TIME COMPLETED:	01:32 PM

ALLEGATION(S):

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Staff failed to obtain medical care in a timely manner for resident who sustained serious injuries after an unwitnessed fall.
Resident was left unattended for an extended period of time

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver findings for the complaint received on 12/20/23. LPA arrived at the facility and explained the purpose of today’s visit and was greeted by executive director (ED) Shannon Howell.

The complaint was investigated by the Department which involved interviews and pertinent records review.

It is alleged that the staff failed to obtain medical care in a timely manner for resident who sustained serious injures after an unwitnessed fall. The investigation revealed that on December 15, 2022, resident (R1) sustained a fall in their room and was not checked on until December 17, 2022. Staff (S1) even stated being “too busy” to check R1 because R1 was “always independent”. R1 personal service assessment plan dated April 5, 2022, stated that R1 has sustained a total of three falls within the past twelve months.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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 4

Control Number 22-AS-20221220140629

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 IRVINE	FACILITY NUMBER: 306002954
	VISIT DATE: 08/03/2023

NARRATIVE

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On R1’s physician report dated March 8, 2022, R1 was diagnosed with mild cognitive impairment. A fall risk assessment evaluation was conducted on April 5, 2022, and it was noted that R1 is a fall risk, and the three falls that were sustained in the span of twelve months, resulted in a hospitalization and with a fracture. On December 17, 2022, staff (S2) went to R1’s room and found R1 on the floor with a laceration on the head, was disoriented, and had dried blood covering their head. Per interview with the S2 upon finding R1 on the floor, it was observed that R1 also had two blood-soaked towels around their head and that R1 reported of having pain in the back of their head. The R1 reportedly had crawled to get towels. It was reported that R1 had “been there for a while as the blood on the towels was as hard as a rock”. On December 17, 2022, 911 was contacted to seek medical attention for R1. R1 was then admitted and evaluated at the hospital, and per hospital staff, R1 sustained injuries, was dehydrated, was soaked in urine, covered in blood and had feces all over. Hospital staff reported that through conversing with S2, S2 expressed being “terrified” because only two caregivers were on duty the night R1 was found. Due to R1 being left unattended from December 15, 2022 to December 17, 2022, the medical attention and care was delayed for R1 who sustained serious injuries: blunt head trauma, concussion, occipital scalp laceration, blunt chest and abdominal trauma and decubitus ulcers to her sacrum.

It was alleged that resident was left unattended for an extended period of time. The investigation revealed that on December 15, 2022, R1 fell and called for help, however, did not receive any assistance from staff. R1’s friend called R1 via phone on December 16, 2022, and twice on December 17, 2022, and did not receive an answer, therefore contacted the facility and requested for a staff member to check on R1. On the evening of December 17, 2022, a staff member finally went into R1’s room based on the concerns that R1’s friend had expressed, and staff on duty discovered R1 laying on the floor and observed injuries and dried blood. There were no facility notes that indicated that staff did resident checks from December 15, 2022 to December 17, 2022. Interviewed staff were unaware of their own facility policy called a safety check policy which required caregivers to check in on their residents at least once at night between the hours of 10:00 p.m. and 6:00 a.m. If staff had checked on the R1, the R1 would not have spent two nights lying on the floor in their room in pain with injuries which required medical attention.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20221220140629

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 IRVINE	FACILITY NUMBER: 306002954
	VISIT DATE: 08/03/2023

NARRATIVE

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Based on the information gathered during the investigation and review of documents obtained the preponderance of evidence standard has been met, therefore the allegations are determined to be SUBSTANTIATED.

The following is being cited and the Immediate Civil Penalty has been assessed and issued per California Code of Regulations, Title 22 Division 6 Chapter 8, per H&S Code Section 1569.49(f).

An exit interview was conducted with ED Howell.

A copy of this report was explained, and appeal rights were provided during the visit.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20221220140629

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 IRVINE	FACILITY NUMBER: 306002954
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/03/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/04/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by:	1 2 3 4 5 6 7	As a plan of correction (POC), facility is to conduct an in-service training to all staff regarding the regulation cited.
	8 9 10 11 12 13 14	Based on the reviewed documents obtained and interviews conducted during the investigation, facility did not obtain timely medical care for seriously injured resident. This poses an immediate health and safety risk for residents in care.	8 9 10 11 12 13 14
Type A 08/04/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs…the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidence by:	1 2 3 4 5 6 7	As a plan of correction (POC), facility is to conduct a training with all staff regarding the regulation cited and will implement and document resident health and safety checks on a daily basis.
	8 9 10 11 12 13 14	Based on the reviewed documents obtained and interviews conducted during the investigation, facility failed to ensure that the resident was regularly checked. This poses an immediate health and safety risk for residents in care.	8 9 10 11 12 13 14

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) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC9099 (FAS) - (06/04)

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