306002962-7-11-2024-22-AS-AJLO-D7BRCW-20240719125459

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002962
Report Date: 07/11/2024
Date Signed: 07/11/2024 04:29:07 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
08/24/2023 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230824151155

FACILITY NAME:	BROOKDALE BROOKHURST		FACILITY NUMBER:	306002962
ADMINISTRATOR:	JOHN GOODWIN		FACILITY TYPE:	740
ADDRESS:	15302 BROOKHURST ST		TELEPHONE:	(714) 775-6775
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY:	164	CENSUS: 93	DATE:	07/11/2024
		UNANNOUNCED	TIME BEGAN:	03:55 PM
MET WITH:	John Goodwin		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Lack of staff supervision resulted in resident being left on the floor for an extended period of time

INVESTIGATION FINDINGS:

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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) John Goodwin and explained the reason for today’s inspection. The investigation into the allegation that lack of staff supervision resulted in resident being left on the floor for an extended period of time revealed the following: During the course of the investigation, Department staff inspected the facility, interviewed AD, witnesses, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Facility Progress Notes from 2023, R1’s Physician’s Report (LIC 602A) dated October 20, 2022, R1’s Brief Interview Mental Status Screening dated June 15, 2021, R1’s Fountain Valley Hospital Medical Records dated June 13, 2023, R1’s Kaiser Medical Records dated June 28, 2023, the facility’s Resident Meal Check Record for the week of June 11, 2023, and the facility’s Progress Notes for R1.
On June 13, 2023, R1’s responsible party called the facility to check on R1 because R1 had not answered their phone calls for two days, facility staff went to check on R1 and found R1 on the floor, R1 was taken to the hospital where they were diagnosed with a broken hip.

Substantiated

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: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

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 6

Control Number 22-AS-20230824151155

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 BROOKHURST	FACILITY NUMBER: 306002962
	VISIT DATE: 07/11/2024

NARRATIVE

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AD advised R1’s responsible party that the facility’s dining staff had not seen R1 for two days but had not informed anyone at the time. Per R1’s Facility Progress Notes from 2023, R1 resided in the assisted living section of the facility from June 18, 2021, to June 13, 2023. Review of R1’s Physician’s Report (LIC 602A) dated October 20, 2022, revealed that R1 did not have dementia or mild cognitive impairment, had no physical health impairments, was ambulatory, and could communicate their needs, leave the facility unassisted, manage and store their own medications, and independently transfer to and from bed. Facility staff had completed R1’s Brief Interview Mental Status Screening dated June 15, 2021, which assessed R1 as having moderate impairment. Interviews with AD, facility staff, and witnesses revealed that R1 lived independently, required very little assistance with daily living tasks, had no history of falls, and was not considered a fall risk. Per AD, facility staff, and witnesses, on June 13, 2023, at 4PM, R1’s responsible party called the facility to check on R1 because R1 had not answered their phone calls for two days, facility staff went to check on R1 and found R1 on the floor, and R1 was taken to the hospital. Review of R1’s Fountain Valley Hospital Medical Records dated June 13, 2023, revealed that on June 13, 2023, R1 was taken to the hospital for an unwitnessed fall and diagnosed with a hip fracture and R1’s Kaiser Medical Records dated June 28, 2023, indicate R1 required surgery for the hip fracture. When interviewed, AD stated that facility staff conduct checks on residents but that residents in assisted living do not require frequent checks because they are issued pendants to call for assistance, R1 ate in the dining room for meals and dining room staff were supposed to use the facility’s Resident Meal Check Record to monitor the residents. The dining room staff admitted they had not been using the facility’s Resident Meal Check Record and did not notice that R1 had not been coming to the dining room for their meals as R1 usually did. LPA reviewed the facility’s Resident Meal Check Record for the week of June 11, 2023, which shows the record was not completed by facility staff that week until after the incident with R1 was discovered. Facility staff interviewed stated that R1 was not seen in the dining room on June 13, 2023 and it is unknown if anyone saw R1 on June 12, 2023, that even if a resident is considered independent their assigned caregiver should know their location. When R1 was found on June 13, 2023, R1’s pendant was out of reach on the dresser and it appeared R1 had been on the floor for a period of time because their clothes were soiled and R1 appeared extremely exhausted. LPA reviewed the facility’s Progress Notes for R1 which indicate that upon being discovered on June 13, 2023, and asked when they fell, R1 stated that they had fallen two or three days ago. R1’s responsible party reported that the last time they spoke with R1 was on June 11, 2023, at 4PM and the information obtained did not reveal that anyone saw or made contact with R1 on June 12, 2023. The information obtained corroborates that lack of care and supervision resulted in R1 being left on the floor for at least 24 hours after their fall while suffering from a hip fracture.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 22-AS-20230824151155

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 BROOKHURST	FACILITY NUMBER: 306002962
	VISIT DATE: 07/11/2024

NARRATIVE

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During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation that lack of staff supervision resulted in resident being left on the floor for an extended period of time. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted and a copy of this report and appeal rights 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: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 22-AS-20230824151155

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 BROOKHURST	FACILITY NUMBER: 306002962
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/12/2024 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services … (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee stated that after the incident with R1 was discovered, staff were retrained on the meal checks and clinical staff were directed to follow up on residents’ meal check status to ensure that the residents’ whereabouts are known.
	8 9 10 11 12 13 14	Based on documents and interviews, the licensee did not ensure R1 received care and supervision when R1 was left on the floor for an extended period of time after their fall while suffering from a hip fracture, which poses an immediate safety risk to persons in care. CIVIL PENALITY ASSESSED.	8 9 10 11 12 13 14	The licensee stated they will submit these training records to LPA by POC due date.
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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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6

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
08/24/2023 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230824151155

FACILITY NAME:	BROOKDALE BROOKHURST		FACILITY NUMBER:	306002962
ADMINISTRATOR:	JOHN GOODWIN		FACILITY TYPE:	740
ADDRESS:	15302 BROOKHURST ST		TELEPHONE:	(714) 775-6775
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY:	164	CENSUS: 93	DATE:	07/11/2024
		UNANNOUNCED	TIME BEGAN:	03:55 PM
MET WITH:	John Goodwin		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Lack of care and supervision resulting in injury while in care.

INVESTIGATION FINDINGS:

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Unsubstantiated

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: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 22-AS-20230824151155

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 BROOKHURST	FACILITY NUMBER: 306002962
	VISIT DATE: 07/11/2024

NARRATIVE

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Regarding the allegation of lack of care and supervision resulting in injury while in care: On June 13, 2023, R1’s responsible party called the facility to check on R1 because R1 had not answered their phone calls for two days, facility staff went to check on R1 and found R1 on the floor, R1 was taken to the hospital where they were diagnosed with a broken hip, and AD advised R1’s responsible party that the facility’s dining staff had not seen R1 for two days but had not informed anyone at the time. Per R1’s Facility Progress Notes from 2023, R1 resided in the assisted living section of the facility from June 18, 2021, to June 13, 2023. Review of R1’s Physician’s Report (LIC 602A) dated October 20, 2022, revealed that R1 did not have dementia or mild cognitive impairment, had no physical health impairments, was ambulatory, and could communicate their needs, leave the facility unassisted, manage and store their own medications, and independently transfer to and from bed. Facility staff had completed R1’s Brief Interview Mental Status Screening dated June 15, 2021, which assessed R1 as having moderate impairment. Interviews with AD, facility staff, and witnesses revealed that R1 lived independently, required very little assistance with daily living tasks, had no history of falls, and was not considered a fall risk. Per AD, facility staff, and witnesses, on June 13, 2023, at 4PM, R1’s responsible party called the facility to check on R1 because R1 had not answered their phone calls for two days, facility staff went to check on R1 and found R1 on the floor, and R1 was taken to the hospital. Review of R1’s Fountain Valley Hospital Medical Records dated June 13, 2023, revealed that on June 13, 2023, R1 was taken to the hospital for an unwitnessed fall and diagnosed with a hip fracture and R1’s Kaiser Medical Records dated June 28, 2023, indicate R1 required surgery for the hip fracture. However, while R1 had a fall and sustained an injury while in care, the information obtained did not corroborate that R1’s fall was caused by lack of care and supervision on the part of the facility.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegation of lack of care and supervision resulting in injury while in care occurred as reported. Although the allegation 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. 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: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

LIC9099 (FAS) - (06/04)

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