306002962-2-20-2025-22-AS-AORZ-DEBNET-20250228092428

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002962
Report Date: 02/20/2025
Date Signed: 02/20/2025 11:46:39 AM

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
07/09/2024 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20240709135536

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: 114	DATE:	02/20/2025
		UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	John Goodwin		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Resident sustained multiple pressure injuries due to neglect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit on this day for the purposes of delivering findings into the above allegation. On this day, LPA was greeted and met with Executive Director John Goodwin.
On July 9, 2024, the Department received a complaint alleging a resident sustained multiple pressure injuries due to neglect. A health and safety visit was conducted by the Department on July 11, 2024, and an investigation initiated. The investigation determined as follows:
Resident 1 (R1) was admitted to the facility on April 12, 2024. Per Physician Report dated June 05, 2024, R1 is able to self manage activities of daily living (ADLs) such as bathing, toileting, and dressing and is not able to communicate their needs. R1’s personal service plan dated May 18, 2024, also notates facility’s assessment that resident is independent in ADLs. On July 02, 2024, R1 was found bleeding on their bathroom floor by Caregiver 1 (C1). C1 called for assistance from facility Med Tech 1 (MT1 and 9-1-1 was activated by Wellness Director Suzette Paige. CONTINUED ON LIC 9099C DATED 02/20/2025

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

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-20240709135536

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: 02/20/2025

NARRATIVE

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R1 was admitted to UC Irvine Medical center where they were admitted with multiple signs of trauma to their face and wounds to their shoulder and knee. Per UCI medical records obtained and interviews conducted with UCI Irvine Medical staff, upon admittance R1 was received covered in urine and feces which R1 appeared to have stayed in for a while. Upon testing and evaluation, R1 was diagnosed with Rhabdomyolysis and an intracranial hemorrhage. Resident was further diagnosed to have pressure wounds to the right maxilla; right deltoid; bilateral knees; and right hand. During interviews, UCI Medical staff reported R1’s wounds were suspected to have been caused from being on the ground for two days.
Per interview with facility Health and Wellness Director Suzette Paige, MT1 reported seeing R1 sometime mid-morning on July 02, 2024. However, interview with MT1 denied seeing R1 the morning of. Despite interviews stating facility policy was to check on residents if they did not show up to meals, interviews with six of six staff could not confirm who checked in on R1 after not showing up to breakfast on July 02, 2024. Interviews with staff reported conflicting statements as to when R1 was last seen.

During an interview, R1 reported they had tripped and fell on their own footing. When asked approximately how long they had been on the floor before being found, R1 stated maybe a day or two. Per interviews with R1’s Designated Power of Attorney (DPOA), R1 was discharged back to the facility following a stay at a Skilled Nursing Facility, however R1 continued to decline due to esophageal conditions and the wound on R1’s knee becoming infected. R1 passed away on August 16, 2024. At the time of interview, Administrator Goodman reported there was a total of 97 residents and routinely three caregivers, one Med Tech, and one Licensed Vocational Nurse (LVN) to assist 97 residents.

Based on interviews conducted and records reviewed, Resident sustained multiple pressure injuries due to neglect. The following is being cited per California Code of Regulations, Title 22, Division 6.

A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f)

An exit interview was conducted and a copy of this report, LIC809-D, appeal rights and confidential names list was provided to Executive Director.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240709135536

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: 02/20/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/21/2025 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464(f)(1)- Basic Services. Basic services shall at a minimum include: 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	Licensee agrees to conduct an in-service on wellness checks and forward proof to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted with staff, residents and records obtained, R1 sustained pressure injuries as a result of having an unwitnessed fall and being left on the floor for approximately one to two days. This poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC9099 (FAS) - (06/04)

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