306002962-6-9-2021-22-AS-SSAS-C4F397-20210628180239

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002962
Report Date: 06/09/2021
Date Signed: 06/09/2021 02:37:21 PM

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
10/20/2020 and conducted by Evaluator James August

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201020112859

FACILITY NAME:	BROOKDALE BROOKHURST		FACILITY NUMBER:	306002962
ADMINISTRATOR:	KIMIA ATAEIAN		FACILITY TYPE:	740
ADDRESS:	15302 BROOKHURST ST		TELEPHONE:	(714) 775-6775
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY:	164	CENSUS: 77	DATE:	06/09/2021
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Danielle Chairez, Business Office Director		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident sustained an injury while in care
Staff did not seek medical attention in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jim August made an unannounced visit to the facility to conclude a complaint investigation. LPA identified himself and discussed the purpose of the visit with Business Office Director Danielle Chairez.
The 10-day initial facility visit was completed on October 22, 2021. The investigation into the allegations that a resident sustained an injury while in care and facility staff did not seek medical attention in a timely manner revealed the following:

The allegations involve resident 1 (R1) sustaining a burn injury on the morning of October 16, 2021 at the facility as a result of a coffee spill and what actions the facility staff took subsequently.
On October 22, 2021, LPA August interviewed Administrator Kimia Ataeian. Ataeian did not observe the incident that morning but was told by Licensed Vocational Nurse (LVN) Staff 1 (S1) that a staff member called her to notify her that R1 had what appeared to be a coffee burn. S1 relayed that the resident refused to go to the hospital that morning. The burn was treated by S1 that morning. CONTINUED ON LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James August	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

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-20201020112859

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: 06/09/2021

NARRATIVE

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Ataeian spoke with the resident that night and was told by the resident that her burn was ok and she did not need to go to the hospital.
On October 22, 2021, LPA August interviewed S1. S1 stated that a caregiver reported to her that, “a resident spilled coffee on her leg”. S1 stated when she looked at R1’s injury there was a slight redness and that it did not exhibit burn symptoms. As such they treated the wound at the facility. S1 stated that she asked R1 on numerous occasions, as well as S1’s daughter if she would go to the hospital on her recommendations and both refused.
On October 22, 2021, LPA August interviewed staff 2 (S2). S2 spoke with R1 the morning of October 17, 2021. S2 stated that R1 told her she was doing much better and did not have any pain. S3 explained to R1 that because of her neuropathy, she may not feel the pain and that it would be best if she saw a doctor. S3 stated that R1 refused multiple times to go see a doctor.
On May 4, 2021, LPA August interviewed R1. R1 stated that a staff member (S3) was pushing her in her wheelchair back to her room after eating breakfast. R1 had hot coffee and, per R1, S3 was moving too fast and when the wheelchair hit a room door strip on the floor, it caused coffee in R1’s thermos to spill on R1’s leg. S3 stated that later that day staff members including an LVN looked at her leg and assured R1 that they could take care of the injury at the facility. The following Monday R1 was having difficulty moving so the facility called an ambulance and R1 was transferred to the hospital. R1 stated she never refused to be taken to the hospital at any time.
On May 18, 2021, LPA August interviewed S3. S3 stated that she would regularly push R1 in her wheelchair from her breakfast table back to her room. R1 would normally have the kitchen fill up her coffee thermos with hot coffee and she would take it back to her room. S3 stated that R1 would always put a lid on the thermos herself and hold the thermos back to her room. On the morning of October 16, 2021, she was notified by R1 to “check my leg, because coffee spilled on my leg”. S3 at that time saw that the coffee thermos did not have the lid tightly secured. R1 then requested that S3 get her a wet rag and some Neosporin. S3 told R1 she needs to see the nurse however R1 refused to see the nurse and to see how her wound was doing at lunch time. Just after leaving R1’s room, S3 called the facility nurse and reported the incident.
LPA August obtained R1’s April 6, 2020 medical assessment which indicated that R1 was able to handle her own food independently.
As such, there is insufficient evidence to corroborate whether the above allegations have occurred. With the information obtained through the means described above, we have found the above allegations unsubstantiated. CONTINUED ON LIC9099C...

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James August	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20201020112859

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: 06/09/2021

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Although the allegations may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violations occurred. No deficiencies were observed, and no citations were issued during this visit. An exit interview was conducted with Business Office Director Danielle Chairez. A copy of this report will be emailed to Administrator Kimia Ataeian.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James August	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

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