306002962-4-1-2024-22-AS-SSAS-D42PY3-20240405114314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002962
Report Date: 04/01/2024
Date Signed: 04/01/2024 01:53:05 PM

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
01/17/2024 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240117162657

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: 106	DATE:	04/01/2024
		UNANNOUNCED	TIME BEGAN:	12:56 PM
MET WITH:	Business Office Manager - Danielle Chairez		TIME COMPLETED:	02:06 PM

ALLEGATION(S):

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Lack of care and supervision resulted in unstageable wound

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver findings. LPA arrived at the facility and explained the purpose of today’s visit, was greeted by business office manager (BOM) Danielle Chairez.

The complaint was investigated by the Department which involved interviews record review. It is alleged that due to lack of care and supervision, resident resulted in getting an unstageable wound.

On January 4, 2024, resident (R1) was sent to the hospital to be evaluated due to exhibiting signs of weakness and confusion. Upon R1 getting discharged from the hospital, an updated physician reported dated for January 6, 2024 stated that R1 is diagnosed with mild cognitive impairment, delirium, has weakness, bladder, visual and motor impairments, however R1 is able to use the bathroom without assistance.

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: 04/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2024

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-20240117162657

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: 04/01/2024

NARRATIVE

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R1 was discharged from the hospital and returned to the facility on January 6, 2024 by R1’s family.
Per R1’s discharge paperwork, R1 showed signs of delirium, but no hospital documentation indicated that R1 had skin breakdown. On January 7, 2024, R1 began home health services with Excell Home Health, and R1 was assessed by the nurse, who also did not report or observe any skin issues. On January 14, 2024, facility staff observed wounds on R1’s sacrum and buttocks while changing R1, and staff notified the home health nurse who cleaned and dressed R1’s wound the same day.

On January 15, 2024, when R1 was being changed, staff observed that R1’s wounds had worsened, therefore, sent R1 out to the hospital to obtain further medical evaluation. An interview was conducted with R1’s family who stated that the facility is not to blame regarding R1’s condition and expressed satisfaction regarding the facility care given to R1.

Based on interviews which were conducted, review of documents obtained, and observations, there is insufficient evidence to ascertain if the allegation occurred as reported, therefore, this allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted with BOM Chairez.

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: 04/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2024

LIC9099 (FAS) - (06/04)

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