306003639-12-31-2024-22-AS-SSAS-DE4CVG-20250221011552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003639
Report Date: 12/31/2024
Date Signed: 12/31/2024 11:34:38 AM

Substantiated

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
12/24/2024 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20241224130741

FACILITY NAME:	BROOKDALE BREA		FACILITY NUMBER:	306003639
ADMINISTRATOR:	DANNY VERA		FACILITY TYPE:	740
ADDRESS:	285 W CENTRAL AVE		TELEPHONE:	(714) 671-7898
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY:	110	CENSUS: 80	DATE:	12/31/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Danny Vera		TIME COMPLETED:	11:47 AM

ALLEGATION(S):

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Staff mismanaged resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the 10-day visit to begin the investigation into the allegation listed above. LPA was greeted and granted entry by staff. LPA met with Executive Director Danny Vera and explained the reason for the visit. LPA interviewed staff. LPA requested documents such as medication administration records, needs and care plans and physician reports. The investigation revealed the following. Resident 1 (R1) went to the hospital on October 17, 2024 and was discharged on October 22, 2024. On the hospital discharge paperwork R1 was ordered to continue taking Clopidogrel 75mg (Plavix). According to the Medication Administration Record (MAR) the medication was not added until December 2024. Staff reported they wanted to verify the order because hosptial discharge paperwork is not accepted by the Pharmacy and they do not accept it as an official order for medication. R1 was handling their own medication prior to the hospital visit from October 17 through October 22, 2024. The hospital contacted the facility and informed them R1 could not manage their own medications. R1 and their family agreed.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024

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-20241224130741

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 BREA	FACILITY NUMBER: 306003639
	VISIT DATE: 12/31/2024

NARRATIVE

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When the facility took control of R1's medication on October 25, 2024 Clopidogrel 75mg (Plavix) was part of the inventory of R1's medication. According to the MAR for R1 they only received Clopidogrel 75mg (Plavix) from December 20, 2024 to December 26, 2024. R1's Clopidogrel 75mg (Plavix) was stored securely in the facility's medication room. The facility did verify the order for the medication but not until December 20, 2024. The discharge paperwork from the hospital is signed by the doctor and is an official order.

Based on the evidence gathered the preponderance of evidence standard has been met; therefore, the above allegation is substantiated. See LIC9099-D for cited deficiency per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20241224130741

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 BREA	FACILITY NUMBER: 306003639
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/31/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/02/2025 Section Cited CCR 87468.1(a)(16)	1 2 3 4 5 6 7	(16) To receive or reject medical care or other services. This requirement was not met as evidenced by,	1 2 3 4 5 6 7	Licensee agrees to train staff on CCR 87468.1 personal rights of residents in all facilities and submit proof of training to the LPA by the POC due date.
	8 9 10 11 12 13 14	a record review shows R1 was prescribed Clopidogrel 75mg (Plavix) on October 22, 2024 but it was not administrered to R1 until December 20, 2024. This poses an immediate health and safety risk to the resident.	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) 334-2062
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024

LIC9099 (FAS) - (06/04)

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