306002954-4-30-2024-22-AS-MVAO-D5JUGE-20240523153409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002954
Report Date: 04/30/2024
Date Signed: 04/30/2024 09:38:17 AM

Unsubstantiated

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
07/30/2020 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200730163608

FACILITY NAME:	BROOKDALE IRVINE		FACILITY NUMBER:	306002954
ADMINISTRATOR:	MICHAEL ARCEO		FACILITY TYPE:	740
ADDRESS:	10 MARQUETTE		TELEPHONE:	(949) 854-3766
CITY:	IRVINE	STATE: CA	ZIP CODE:	92612
CAPACITY:	155	CENSUS: 93	DATE:	04/30/2024
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Sharrin Belenger, Bussiness Office Manager		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Resident sustained an injury from a fall while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA met with Sharrin Belenger, Bussiness Office Manager and explained the nature of the visit.

Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegation. Findings are based upon this investigation which included interviews conducted and copies of pertinent documents obtained (hospital records, SOC341 and residents facility file). It is alleged that resident sustained an injury from a fall while in care. Hospital records revealed that the attending physician indicated per patient's DPOA with whom he had a lengthy discussion over the telephone who informed doctor that the patient has had multiple hospitalizations since December 2019 initially multiple times at Mission Regional Medical Center followed by multiple recent hospitalizations at Hoag Hospital

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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-20200730163608

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 IRVINE	FACILITY NUMBER: 306002954
	VISIT DATE: 04/30/2024

NARRATIVE

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Newport Beach. DPOA is concerned that the patient has progressively declined and has had a recent change in residents (R1) physicians due to transition of care from Mission Hospital to Hoag Newport. R1 is aware that they fell and R1 did not use the walker as R1 was recommended to, denies any true loss of consciousness and on my current evaluation denies any acute complaints either. Hospital records revealed that on July 30, 2020, hospital social worker spoke with R1's DPOA and DPOA reported that R1 is at an assisted living facility for three months and the facility has been up front and transparent with the DPOA that R1 would benefit from a facility that would be able to provide a higher level of care. DPOA stated that they have been seeking out an appropriate facility for a couple of weeks now. Interview with staff 1 of 1 (S1) revealed that they spoke to R1’s daughter and informed her that R1 needed a higher level of care. Resident records revealed that R1 was admitted to the facility on May 09, 2020. R1 records for personal service plan was completed upon admission to facility. Personal service Plan indicate that R1 had changes to their care for a high care assistance on the following dates: June 01, 2020, June 2, 2020, July 23, 2020 and August 19, 2020. Personal service plan had updates on those dates for more care. Facility records revealed that R1 received an update personal service plan for the following services: dressing and grooming, showering, or bathing, bathroom assistance, escort & mobility and added service coordination. Incident report received indicates that on July 28, 2020 R1 pulled pendent, LVN assessed R1 for a fall and R1 indicated they had hit their head. Staff immediately called 911 and R1 was transported to the hospital for further evaluation.

Based on the information gathered during the investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

This report was reviewed with facility reprensetative and a copy was furnished to the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC9099 (FAS) - (06/04)

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