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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336413087
Report Date: 04/10/2023
Date Signed: 04/10/2023 06:03:36 PM

Substantiated


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
02/23/2022 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220223120053
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: 58DATE:
04/10/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Executive Director Cindy Garcia TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility did not notify resident's family of resident's fall(s).
Staff did not report resident's fall(s) to the facility.
Staff threatened resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation pertaining to the allegation(s) listed above. LPA was greeted and entry by Hanofi Edogiawerie Health and Wellness Director. LPA met with Executive Director Cindy Garcia and explained the purpose of the visit. The allegation(s) noted above were investigated. The investigation consisted of observations, interviews and record review.
Regarding the allegation of facility did not notify resident's family of resident's fall(s). Resident #1 (R1) was admitted to the facility on September 21, 2015. R1 was noted to have a motor impairment as they have weakness and neuropathy. As a result, R1 used a wheelchair, walker and required a two-person assist. On October 11, 2021 R1 did sustain a fall where they reportedly rolled out of their bed, that was stated to not have been reported, by the previous administrator Queen Ayers. Queen was not aware of the incident until having to follow up on it amongst other reported concerns. Queen reported that there was a fall that did occur on October 11, 2021 during the NOC shift and that R1’s family was not notified. Additionally, R1 was noted to have an unreported fall on December 25, 2021, while allegedly being transferred from their
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
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 6
Control Number 18-AS-20220223120053
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: 04/10/2023
NARRATIVE
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wheelchair regular chair. A review of documentation revealed that on or around December 27, 2021 R1 had sustained a fall and was noted to be leaning on their right side with increased weakness. A facility file review revealed that the facility did submit an unusual/special injury report to the regional office on December 28, 2021 for being sent out due to elevated blood pressure, however the diagnoses given at the emergency room was a broken hip, requiring surgery and rehabilitation. Therefore, the allegation of facility did not notify resident's family of resident's fall(s) Is SUBSTANTIATED.

Staff did not report resident's fall(s) to the facility.
R1 was noted to have a motor impairment as they have weakness and neuropathy. As a result, R1 used a wheelchair, walker and required a two person assist. A review of documentation revealed that on October 11, 2021 R1 did sustain a fall that was noted to not have been reported, by the previous administrator Queen Ayers. Queen was not aware of the incident until having to follow up being asked about a fall, amongst other reported concerns. Queen reported that there was a fall that did occur on October 11, 2021 during the NOC shift and that R1’s family was not notified. Based on record review the allegation of staff did not report resident's fall(s) to the facility is SUBSTANTIATED.

Staff threatened resident
It was reported that sometime in October 2021 that staff #1 (S1) would only assist R1 with getting dressed if they got up at 4:00am. In addition, S1 forces R1 to sit on the lid of the commode that is described as being hard. Further reports stated that if R1 was complaint to S1 then they will be left to sit not dressed until their next shift. It was also reported that R1 stated that S1 was mean to them and that they were afraid to speak up, as doing so would make matters worse out of retaliation. Additionally, an internal investigation was conducted and S1 was not to provide any care unless it was an emergency until they could be retrained. Based on observation and record review the allegation is SUBSTANTIATED. A SUBSTANTIATED finding means that the preponderance of evidence standard has been met. Therefore the allegation is substantiated.

An exit interview was conducted, and a copy of this report, 9099d, appeal rights, and LIC 811 were reviewed and provided to Executive Director Cindy Garcia.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 18-AS-20220223120053
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: 04/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2023
Section Cited
CCR
87211
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REPORTING REQUIREMENTS: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following: (1) A written report shall be submitted to the licensing agency...within 7 days of the occurrence of any of the events specified in (A) - (D)... (D) Any
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The Administrator agrees to conduct a staff training on reporting requirements. Proof is to be submitted to the department by 5 pm on the due date indicated.
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incident which threatens the welfare, safety or health of any resident...This requirement was not met, as evidenced by: Based on interviews the Licensee didn't ensure R1's hospitalization was reported to the Licensing agency. This poses a potential risk to the health, safety or personal rights of the residents in care.
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Type B
04/24/2023
Section Cited
CCR
87211
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Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following: (1) A written report shall be submitted to the licensing agency...within 7 days of the occurrence of any of the events specified
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incident which threatens the welfare, safety or health of any resident...This requirement was not met, as evidenced by: Based on interviews the Licensee didn't ensure R1's hospitalization was reported to the Licensing agency. This poses a potential risk to the health, safety or personal rights of the residents in care
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The Administrator agrees to conduct a staff training on change of condition. Proof is to be submitted to the department by 5 pm on the due date indicated.
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: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20220223120053
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: 04/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2023
Section Cited
CCR
87468.1(a)(2)
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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES: (a) Residents in all RCFEs shall have all of the following personal rights: To be accorded safe, healthful & comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on documentation review
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The Licensee agrees to conduct a training on personal rights. Proof is to be submitted to the dept by 5pm on the due date indicated.
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the licensee did not comply with the section cited above. R1 was uncomfortable as they feltht wy would be retailiated against if they spoke up. This posed an immediate risk to the personal rights of the resident 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: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
02/23/2022 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220223120053

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: 58DATE:
04/10/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Executive Director Cindy Garcia TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff dropped resident during transferring.
Facility did not seek resident timely medical attention for a broken hip
Staff handled resident in a rough manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation pertaining to the allegation(s) listed above. LPA was greeted and entry by Hanofi Edogiawerie Health and Wellness Director. LPA met with Administrator Cindy Garcia and explained the purpose of the visit. The allegation(s) noted above were investigated. The investigation consisted of observations, interviews and record review.

Staff dropped resident during transferring.
It was reported that sometime in October 2021, that R1 was dropped while being transferred. Interviews conducted revealed that staff denied dropping R1 while being transferred. It was reported that staff “forced” R1 to walk without their walker while transferring from their chair and to their bed, and that at that time R1’s legs gave out. A review of documentation notes review of documentation notes R1 also stated that they were in fact being supported by staff at the time of transfer. Based on interviews and record review. The allegation of staff dropped while being transferred is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20220223120053
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: 04/10/2023
NARRATIVE
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Facility did not seek resident timely medical attention for a broken hip.
Regarding the facility did not seek resident timely medical attention for a broken hip. A review of documentation revealed that on or around December 27, 2021 R1 had sustained a fall and was noted to be leaning on their right side with increased weakness. Further documentation reviewed revealed that R1 was not complaining of any pain or discomfort. In addition, a review of documentation revealed that on December 28, 2021 R1 was noted to have elevated blood pressure. A further review revealed that prior to being noted to have elevated blood pressure, R1 was noted to have had slid off of their bed and did not have any injuries. R1 was sent out for a medical evaluation after staff observing that R1's blood pressure was elevated. Based on record review the allegation of facility did not seek resident timely medical attention for a broken hip is UNSUBSTANTIATED.

Staff handled resident in a rough manner
Regarding the allegation of staff handled resident in a rough manner. A review of documentation revealed that when staff helps R1 up that they pull them by their arm, and that other staff helps R1 by giving a little push on their back. Interviews conducted revealed that R1 would fall back, sticking their arms and legs out when being transferred, making it difficult at times. Including when being transferred from their wheelchair R1 preferred to have the leg extenders out. Staff reported to have to give constant reminders as having the leg extenders out could result in an injury. A further review of documentation revealed that when an internal investigation was conducted and that R1 refused to use the gait belt and wanted to be pulled up by their arms when being transferred. Further information notes that R1 felt that they were being pushed when staff placed their hands on their back, but other feedback notes that R1 preferred to have a hnd on their back.. Due to the conflicting information the allegation of staff handled resident in a rough manner is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted, and a copy of this report, 9099d and LIC 811 were reviewed and provided to Executive Director Cindy Garcia.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6