306002962-6-9-2021-22-AS-SSAS-C4G2D3-20210629171738

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002962
Report Date: 06/09/2021
Date Signed: 06/09/2021 02:42:12 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
02/25/2021 and conducted by Evaluator James August

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210225161525

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:	01:16 PM
MET WITH:	Danielle Chairez, Business Office Director		TIME COMPLETED:	02:37 PM

ALLEGATION(S):

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Questionable Death
Residents left in soiled diapers for a prolonged time
Facility is understaffed
Facility staff did not provide appropriate care and supervision to resident
Facility has mold
Facility is in disrepair

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 March 4, 2021. The investigation into the allegations of questionable death, residents left in soiled diapers for a long time, facility is understaffed, facility staff did not provide appropriate care and supervision, facility has mold and facility is in disrepair revealed the following:
The allegations as stated above involve resident 1 (R1).
On March 4, 2021 LPA August interviewed witness 1 (W1). W1 stated that she would visit the facility frequently and noticed that the caregivers would place pads on resident beds to catch urine. W1 stated that this was done as diapers were not being changed timely. W1 also claimed that she saw mold in one of the bathrooms and noticed a leaking sink once. 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)

Page: 1 of 5

Control Number 22-AS-20210225161525

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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On March 4, 2021, LPA August interviewed Administrator Kimia Ataeian. Ataeian stated that R1 passed away on February 8, 2021 and the cause of death as reported on the death certificate was cardiorespiratory failure with an underlying cause of Covid-19. However, Ataeian reported that R1 was tested weekly for Covid-19 and never tested positive. R1’s last negative Covid-19 test was on February 1, 2021. R1 then received shot #1/2 of the Covid-19 Pfizer Vaccine on February 6, 2021. Ataeian stated that after the vaccine, R1’s health began to decline. On February 7, 2021, R1 was noted with having weakness and poor appetite and on February 8, 2021 R1 was placed on hospice care.
Ataeian stated that all staff are trained to regularly change residents soiled garments in a timely fashion and the facility was sufficiently staffed to meet the needs of residents. Ataeian stated there have never been any reports of mold at the facility and the if anything at the facility is in disrepair it is repaired immediately.
On March 4, 2021 LPA August interviewed staff 1 and staff 2 (S1 and S2). S1 and S2 stated that all of the staff at the facility do a good job with the residents and are all trained. Both staff stated that none of the staff in the memory care unit of the facility leave residents unattended or in soiled diapers for long. Both staff stated that the amount of staffing in the memory care unit has never prohibited them from taking care of the residents as required. Both staff have never seen any mold at the facility and have not seen anything in disrepair.
On March 4, 2021 LPA August inspected R1’s room and did not see any signs of mold, or disrepair in the room. LPA August inspected another random resident bedroom and the room appeared to be clean and orderly. There was no visible mold in the bathrooms and the sinks were not leaking. On June 9, 2021 LPA August inspected a random resident room at the facility. The room and bathroom were in good repair and clean, with no visible signs of mold.
LPA August obtained a copy of R1’s death certificate which confirmed that R1 passed away on February 8, 2021 as a result of cardiorespiratory failure with an underlying cause of Covid-19. LPA August also obtained a copy of R1’s last covid-19 test which was administered on February 1, 2021 and results returned on February 2, 2021.
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. 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)

Page: 2 of 5

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
02/25/2021 and conducted by Evaluator James August

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210225161525

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:	01:16 PM
MET WITH:	Danielle Chairez, Business Office Director		TIME COMPLETED:	02:37 PM

ALLEGATION(S):

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Staff did not seek timely medical care for resident

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 March 4, 2021. The investigation into the allegation that staff did not seek timely medical care for a resident revealed the following:
The allegation as stated above involve resident 1 (R1).

On March 4, 2021, LPA August interviewed Administrator Kimia Ataeian. Ataeian stated that R1 passed away on February 8, 2021 and the cause of death as reported on the death certificate was cardiorespiratory failure with an underlying cause of Covid-19. However, Ataeian reported that R1 was tested weekly for Covid-19 and never tested positive. R1’s last negative Covid-19 test was on February 1, 2021. CONTINUED ON LIC9099C...

Substantiated

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)

Page: 3 of 5

Control Number 22-AS-20210225161525

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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R1 then received shot #1/2 of the Covid-19 Pfizer Vaccine on February 6, 2021. Ataeian stated that after the vaccine, R1’s health began to decline. On February 7, 2021, R1 was noted with having weakness and poor appetite and on February 8, 2021 the facility called a Nurse Practitioner who ordered hospice care for R1. Brookdale Hospice arrived at the facility the same day and began the paperwork in order to admit R1 to hospice care, however as the hospice care staff were working on the paperwork, R1 passed away. Therefore, the order for hospice care was not completed and no paperwork was drafted for R1. Administrator Ataeian stated that the facility did not call 911 as the resident was officially declared to be on hospice by her nurse practitioner and the resident was passing away of what was assumed to be natural causes.
Based on the above, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficiency is a violation of Title 22, Division 6, of the California Code of Regulations.
An exit interview was conducted with Danielle Chairez and a copy of this report along with appeal rights 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)

Page: 4 of 5

Control Number 22-AS-20210225161525

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: 06/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/10/2021 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...This regulation was not met as evidence by:	1 2 3 4 5 6 7	Licensee to ensure immediate medical attention is sought if an injury or other circumstance has resulted in an imminent threat to a resident's health. Licensee has agreed to an in-service staff training regarding this requirement and hospice care.
	8 9 10 11 12 13 14	Licensee did not call 9-1-1 before resident 1 (R1)'s passing. R1 was not admitted to hospice care, by hospice care staff at the point when R1 expired. This poses an immediate health and safety risk to persons 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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

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