306002962-2-9-2024-22-AS-SSAS-D2R3HS-20240223171625

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002962
Report Date: 02/09/2024
Date Signed: 02/09/2024 11:15:54 AM

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
02/01/2024 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240201085538

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: 97	DATE:	02/09/2024
		UNANNOUNCED	TIME BEGAN:	08:13 AM
MET WITH:	Health and Wellness Director- Suzette Paige		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Resident sustained multiple falls due to lack of care and supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility for the complaint and to deliver the findings. LPA De Perio explained the purpose of today's visit, and was greeted by Health and Wellness Director (HWD) Suzette Paige.

During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed.

It was alleged that resident sustained multiple falls due to lack of care and supervision. 2 out of 2 staff interviews did not corroborate with the allegation by stating that upon resident (R1) sustaining a fall in room, R1 pressed their pendent button, of which 2 staff responded within 9 minutes. Upon staff responding, a body assessment was conducted on R1, and 911 was immediately contacted, of which R1 was taken to the hospital for further evaluation. R1 is currently not residing at the facility and was admitted to skilled nursing for additional monitoring for a condition unrelated to R1’s fall.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

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-20240201085538

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 BROOKHURST	FACILITY NUMBER: 306002962
	VISIT DATE: 02/09/2024

NARRATIVE

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Per documentation review, R1 is able to bathe, and dress self, is not diagnosed with mild cognitive impairment or dementia, is ambulatory, has a history of falls, and when R1 is anxious, R1 will engage in behavior such as placing self on the floor. Documentation revealed that R1 had one fall on January 30, 2024, and sustained no other falls the month prior and after.

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation 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 with HWD Paige.

A copy of this report was provided and explained

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

LIC9099 (FAS) - (06/04)

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