306002955-10-30-2024-22-AS-SSAS-DAYQ6U-20241113105406

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002955
Report Date: 10/30/2024
Date Signed: 10/30/2024 03:40:22 PM

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
07/03/2024 and conducted by Evaluator Alvaro Ramirez Jr.

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240703101647

FACILITY NAME:	BROOKDALE NOHL RANCH		FACILITY NUMBER:	306002955
ADMINISTRATOR:	KELLY JACOBS		FACILITY TYPE:	740
ADDRESS:	380 S ANAHEIM HILLS RD		TELEPHONE:	(714) 974-1616
CITY:	ANAHEIM HILLS	STATE: CA	ZIP CODE:	92807
CAPACITY:	266	CENSUS: 66	DATE:	10/30/2024
		UNANNOUNCED	TIME BEGAN:	09:52 AM
MET WITH:	Executive Director-Sarah DeVore		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not administer prescribed medication to a resident in care.
Staff is smoking a vape pen inside of the facility.
Staff did not properly bathe a resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on July 03, 2024. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Sarah DeVore. LPA explained the reason for the visit.

This Department has investigated the complaint alleging that staff did not administer prescribed medication to a resident in care, staff is smoking a vape pen inside of the facility and staff did not properly bathe a resident in care. Resident 1 (R1) was admitted to the facility on February 28, 2024. Regarding the allegations, the following was revealed: During the course of the interviews six of seven individuals interviewed denied the allegations. During the course of the investigation LPA reviewed documents including the Physician Report (LIC602A) dated March 15, 2024 for R1. Per Physician Report R1 is able to administer own prescription medications. During the course of the interviews with residents, R1 stated that staff administer her medications properly and timely. Per R1 she is not aware if she takes pain killers and/or Norco.
CONTINUED ON LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

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-20240703101647

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 NOHL RANCH	FACILITY NUMBER: 306002955
	VISIT DATE: 10/30/2024

NARRATIVE

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LPA reviewed documents including the Medication Administration Record (MAR) dated July 01, 2024 to July 31, 2024 for R1. Per MAR R1 was prescribed Acetaminophen 500 MG. Per MAR Acetaminophen 500 MG was prescribed as Pro Re Nata (PRN)/as needed. Per tylenol.com Acetaminophen is the primary ingredient in Tylenol.

Regarding the allegation that staff is smoking a vape pen inside of the facility, the following was revealed: During the course of the interviews with residents, R1 reported that she has not witnessed staff smoking a vape inside the facility. Per R2 she has not seen staff or the Director smoking inside the facility. Documents reviewed included the 2024 Brookdale Associate Handbook. Per Brookdale Associate Handbook under Smoke-Free Environment it states smoking and the use of tobacco products are allowed only in designated areas outside of the buildings. During the initial visit on July 11, 2024 and today's visit LPA observed a designated smoking area located on the first floor.

Regarding the allegation that staff did not properly bathe a resident in care, the following was revealed: During the course of the interviews with residents, R1 stated that staff assist her with her showers and reported that staff do a great job. Per R1 she has not complaints. LPA reviewed documents including the Personal Service Plan dated July 01, 2024 for R1. Per Personal Service Plan R1 needs assistance with showers two times per week. Per Personal Service Plan R1 prefers to shower on Sundays and Thursdays between 5:00 pm and 6:00 pm. During the course of the interviews with staff, Staff 1 (S1) reported that no resident has complained about not being showered properly. Per S2 staff do their best when bathing the residents and stated that residents get two showers per week.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED.

For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations.

LPAs conducted an exit interview with facility representative, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024

LIC9099 (FAS) - (06/04)

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