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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336413087
Report Date: 02/26/2021
Date Signed: 02/26/2021 02:11:24 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2020 and conducted by Evaluator Kiana Clark
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200727141154
FACILITY NAME:BROOKDALE MURRIETAFACILITY NUMBER:
336413087
ADMINISTRATOR:QUEEN AYERSFACILITY TYPE:
740
ADDRESS:24350 JACKSON AVETELEPHONE:
(951) 696-5753
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:82CENSUS: 69DATE:
02/26/2021
UNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Queen AyersTIME COMPLETED:
11:31 AM
ALLEGATION(S):
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Staff did not respond to call button in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kiana Clark contacted the facility via telephone to conclude a complaint investigation due to COVID-19. LPA Clark identified herself and discussed the purpose of the call with Administrator Queen Ayers.

The investigation consisted of interviews with facility staff, resident #1 (R1), outside parties, and documents received. The allegation indicates that staff did not respond to the call button in a timely manner. On 07/25/20, R1 utilized the call button to ask for assistance. Based on documentation and interviews, LPA Clark concluded that the call was not responded to in a timely manner as the response time was determined to be well over 15 minutes. This poses a potential health and safety risk to the resident in care.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Kiana ClarkTELEPHONE: (951) 218-3893
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021
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 18-AS-20200727141154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BROOKDALE MURRIETA
FACILITY NUMBER: 336413087
VISIT DATE: 02/26/2021
NARRATIVE
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Based on LPA Clark’s observations and interviews, which were conducted, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

An exit interview was conducted with the Administrator via a tele-visit and a copy of this report, LIC9099D, and appeal rights, were provided to the Administrator via email. Report with facility representative signature was obtained.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Kiana ClarkTELEPHONE: (951) 218-3893
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2020 and conducted by Evaluator Kiana Clark
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200727141154

FACILITY NAME:BROOKDALE MURRIETAFACILITY NUMBER:
336413087
ADMINISTRATOR:QUEEN AYERSFACILITY TYPE:
740
ADDRESS:24350 JACKSON AVETELEPHONE:
(951) 696-5753
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:82CENSUS: 69DATE:
02/26/2021
UNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Queen AyersTIME COMPLETED:
11:31 AM
ALLEGATION(S):
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Staff wouldn't let family bring residents personal belongings into her apartment
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kiana Clark contacted the facility via telephone to conclude a complaint investigation due to COVID-19. LPA Clark identified herself and discussed the purpose of the call with Administrator Queen Ayers.

The investigation consisted of interviews with facility staff, resident #1 (R1), outside parties, and documents received. The allegation indicates staff would not let family bring resident’s personal belongings into their apartment. Interviews with the administrator, R1, and outside parties confirmed that R1’s belongings were delivered. There is not a preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is unfounded.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Kiana ClarkTELEPHONE: (951) 218-3893
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021
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 18-AS-20200727141154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BROOKDALE MURRIETA
FACILITY NUMBER: 336413087
VISIT DATE: 02/26/2021
NARRATIVE
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No deficiencies were cited during this visit. An exit interview was conducted with the Administrator via a tele-visit and a copy of this report was provided to the Administrator via email. Report with facility representative signature was obtained.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Kiana ClarkTELEPHONE: (951) 218-3893
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20200727141154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROOKDALE MURRIETA
FACILITY NUMBER: 336413087
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2021
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as
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Complete refresher training for all staff regarding appropriate response times for persons in care.
Proof will be submitted to the Department by 03/05/21.
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required in Section 87608, Postural Supports. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure the call button was responded to in a
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DEF CONT'D. timely manner for R1 which poses a potential health risk to persons in care.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Kiana ClarkTELEPHONE: (951) 218-3893
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5