306002954-8-26-2022-22-AS-MSTC-CJ55GH-20220909195643

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002954
Report Date: 08/26/2022
Date Signed: 08/26/2022 01:18:25 PM

Unfounded

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
08/19/2022 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220819135812

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: 101	DATE:	08/26/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Becky Kruse		TIME COMPLETED:	01:32 PM

ALLEGATION(S):

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Facility is not answering communications promptly to the resident's representatives.
Facility is not providing resident's records to the resident's representatives.

INVESTIGATION FINDINGS:

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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Wellness Director (WD) Becky Kruse and explained the reason for today’s inspection.

The investigation into the allegations that Facility is not answering communications promptly to the resident's representatives and Facility is not providing resident's records to the resident's representatives revealed the following: During the course of the investigation, LPA interviewed WD and Staff #1 (S1) and requested and reviewed the resident file for Resident #1 (R1).

It was reported that a family member of R1 requested R1’s records from the facility, that the facility did not provide the records, and that after requesting additional documentation from the family member and not receiving it, the facility stopped responding to the family member.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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-20220819135812

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: 08/26/2022

NARRATIVE

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LPA interviewed WD and S1 who stated that the facility’s privacy policy is to only release a resident’s records with a signed release. LPA reviewed the facility’s Notice of Privacy Practices, top of page 6, which states “Brookdale is required by law to maintain the privacy of Protected Health Information (“PHI”) and to provide you notice of our legal duties and privacy practices with respect to PHI.”. The Notice of Privacy Practices, bottom of page 6, identifies the following “uses and disclosures of PHI that do not require prior authorization”: “1. For Treatment,” “2. For Payment,” and “3. For Health Care Operations.” The Notice of Privacy Practices, middle of page 7, states that the facility “may also use and disclose your PHI without your prior authorization for these purpose”: “5. Disclosures to Family, Friends or Others Designated by You. We may disclose your PHI to a close friend, family member or other relative, or a person you designate, who is involved in your care or payment for your care, to the extent that the information is relevant to their involvement in your care. An example of this is if a family member transports and assists you with physician visits and staff gives them PHI necessary for a physician visit. If there is a person to whom you do not wish us to disclose the above information, please notify the Privacy Office. We may also use or disclose your PHI to notify (or assist in notifying) a family member, legally authorized representative or other person responsible for your care of your location, general condition or death.” WD and S1 stated that R1 had no POA or conservator. LPA’s review of R1’s file corroborated this statement and also revealed that R1 did not have a diagnosis of Dementia. LPA’s review of R1’s file revealed 2 other family members who signed various paperwork for R1 and were listed as contacts for the facility. However, the family member at issue was not listed as an emergency contact on R1’s Identification and Emergency Information (LIC601) and LPA did not see this individual’s name anywhere in R1’s file. Based on the evidence obtained, the facility was not required to provide the records requested or to continue communicating with this family member.

The Department has investigated the above allegations and found them to be Unfounded, meaning the allegation were false, could not have happened, or are without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC9099 (FAS) - (06/04)

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