336413087-6-12-2023-18-AS-JESL-CTB3QG-20230630182708

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336413087
Report Date: 06/12/2023
Date Signed: 06/12/2023 11:15:23 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
06/07/2021 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210607133843

FACILITY NAME:	BROOKDALE MURRIETA		FACILITY NUMBER:	336413087
ADMINISTRATOR:	QUEEN AYERS		FACILITY TYPE:	740
ADDRESS:	24350 JACKSON AVE		TELEPHONE:	(951) 696-5753
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92562
CAPACITY:	82	CENSUS: 58	DATE:	06/12/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Health and Wellness Director Hanofi Adogiawerie		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff neglect resulted in resident becoming malnourished and dehydrated
Staff failed to follow resident's plan of care
Resident was deprived of oxygen
Facility failed to provide sanitary conditions in resident's bedroom
Facility does not have enough staff to meet resident's need

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Tricia Danielson and Cheryl Goodrich arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Health and Wellness Director Hanofi Adogiawerie and explained the purpose of the visit.
Regarding the allegation "Staff neglect resulted in resident becoming malnourished and dehydrated" and "Facility failed to follow residents plan of care", it was alleged Resident #1 (R1) was not provided assistance with eating their meals, as agreed upon when admitted to the facility. A review of the admission agreement, R1 was admitted on 03/16/2021. It was further alleged that R1 was not woken up when meals were delivered to their room. Although it was alleged that R1 was dehydrated, it was also simultaneously reported by the Complainant that on several occasions, empty water bottles were found in R1’s room. A review of R1’s physician report dated 01/27/2021, revealed R1 was able to feed self. A review of R1’s Personal Service Assessment dated 03/12/2021, which is completed by the resident and/or the resident’s responsible party, revealed the question regarding if the resident requires direct physical assistance while eating is marked “no.” A review of R1’s Personal Service Plan dated April 14, 2021, R1 requires queuing and informing resident when food is in front of them. Interviews were conducted with (CONTINUED ON LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

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 5

Control Number 18-AS-20210607133843

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROOKDALE MURRIETA	FACILITY NUMBER: 336413087
	VISIT DATE: 06/12/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(CONTINUED FROM LIC9099)
eleven (11) facility staff and hospice staff. Three (3) of eleven interviews revealed, either the staff did not work at the facility during R1's residency or did not remember R1. Seven (7) of eleven (11) interviews revealed R1 was able to eat and drink without assistance and was awakened, if asleep, when their meal/fluids were delivered. R1 was unable to be interviewed.
Regarding the allegation "Resident was deprived of oxygen", it was alleged that on 04/28/2021 R1 was found unconscious, without their oxygen, having trouble breathing, and that R1's oxygen machine was found to be turned off and out of reach. It was further alleged that R1 was to be on oxygen 24/7 as ordered by their physician yet R1 had been found sitting at their table without oxygen on multiple occasions. Several records pertaining to R1 were reviewed. Review of R1's Physician's Report dated 01/27/2021 indicated R1 was not able to administer their own oxygen. A review of R1’s Personal Service Assessment dated 03/12/2021, indicated R1 required the use of oxygen or respiratory equipment and either R1 or their physician believed R1 needed help such as staff attention or physical assistance with the use of oxygen or respiratory equipment. Alternatively, review of R1's Personal Service Plan dated 04/14/2021 revealed R1 was independent with using oxygen or respiratory equipment. The Personal Service Plan was signed by R1's responsible party on this same date. Interviews were conducted with twelve (12) facility staff and hospice staff regarding R1's oxygen use. Four (4) staff/witnesses interviewed reported R1 was known to remove the oxygen. One (1) staff interviewed reported they could not recall any issues or concerns regarding R1's oxygen use. No interviews corroborate that R1 was found unconscious at any time. Investigation did not find that R1 required medical attention on or around 04/28/2021. R1 was unable to be interviewed.
Regarding the allegation "Facility failed to provide sanitary conditions in residents bedroom", it was alleged that the carpet around R1's bedside commode had urine on it and staff failed to clean it timely. A witness interview claims it took two weeks for the facility to clean the carpet. Facility staff report the carpet was cleaned the same day. R1 was unable to be interviewed. The investigation did not find any documents to corroborate or refute the allegation.
Regarding the allegation "Facility does not have enough staff to meet resident’s needs", it was alleged that R1 required assistance in using the bathroom and on more than one occasion staff would respond 30 minutes after R1 had activated their call button or staff would not respond at all. Interviews were conducted with ten
(10) residents and one (1) witness. Two (2) residents were unreliable historians and one (1) resident reported they had never utilized their call button. Six (6) residents interviewed reported they found staff response times to call buttons to be "not very long", "come pretty quickly", "usually quickly", "not very long", "3 to 5 minutes", and "5 minutes, something reasonable". (CONTINUED ON LIC812-C)

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 18-AS-20210607133843

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROOKDALE MURRIETA	FACILITY NUMBER: 336413087
	VISIT DATE: 06/12/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(CONTINUED FROM LIC9099-C)
One (1) resident reported they found staff response times to call buttons to be "sometimes a long time and some caregivers are great!". One (1) witness interviewed reported they had observed staff response times to call buttons to be "mostly quickly". R1 could not be interviewed. Investigation did not reveal documents to corroborate nor refute call times.

Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided along with LIC811- Confidential Names list.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
06/07/2021 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210607133843

FACILITY NAME:	BROOKDALE MURRIETA		FACILITY NUMBER:	336413087
ADMINISTRATOR:	QUEEN AYERS		FACILITY TYPE:	740
ADDRESS:	24350 JACKSON AVE		TELEPHONE:	(951) 696-5753
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92562
CAPACITY:	82	CENSUS: 58	DATE:	06/12/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Health and Wellness Director Hanofi Adogiawerie		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff neglect resulted in resident sustaining a pressure injury
Unqualified staff caring for resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Health and Wellness Director Hanofi Adogiawerie and explained the purpose of the visit.
Regarding the allegation "Staff neglect resulted in resident sustaining a pressure injury", it was alleged that when R1 was moved to another facility, a doctor evaluation found R1 to have an infection in their tailbone and an ulcer on their lower back. A report reviewed from Doctors on Wheels dated 05/06/2021, revealed R1 presented with a “grade 1 decub ulcer natal cleft”. Hospice Notes dated 04/26/2021, revealed R1 was last seen by the hospice RN at Brookdale Murrieta on this same date. Notes documented by the hospice RN indicated R1's skin to be intact, dry, warm, with no abnormalities. R1 moved out of Brookdale Murrieta into another facility on 05/02/2021. Hospice treatment continued at the new facility and the first visit was conducted on 05/03/2021 and notes documented for that visit do not indicate any mention of a pressure injury. A subsequent hospice visit was conducted at the new facility on 05/04/2021 and notes documented for that visit do not indicate any mention of a pressure injury. Interview with an additional hospice RN (CONTINUED ON LIC9099-C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

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 5

Control Number 18-AS-20210607133843

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROOKDALE MURRIETA	FACILITY NUMBER: 336413087
	VISIT DATE: 06/12/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(CONTINUED FROM LIC9099-A)
revealed they had visited R1 at the new facility "within a day or two of being placed". The RN reported that when R1 came into placement to the new facility, R1 had a "reddened area" on their coccyx. R1 was examined by R1's responsible party's personal doctor on 05/06/2021 at the new facility. Notes documented for that visit revealed R1 was observed to have "erythema without skin breakdown at top nadal cleft" and "grade 1 decub ulcer natal cleft". The doctor's notes do not indicate an order for treatment for it. On 05/13/2021, the doctor visited R1 once again at the new facility and notes reviewed for that visit revealed the grade 1 decub ulcer to R1's natal cleft had progressed to a grade 2. Review of progress notes for R1 at the new facility revealed no mention of a redness to R1’s coccyx upon admission. Progress notes for the overnight shift of 05/04/2021 to 05/05/2021, three days after R1’s admission to the new facility, revealed R1 was rotated every two hours because of skin breakdown. There is no mention of where the skin breakdown was located.
Regarding the allegation "Unqualified staff caring for resident", it was alleged that on one occasion the facility bus driver was assisting R1 due to staffing being short that day. Interview was conducted with Staff #1 (S1) who was identified as the bus driver observed providing care for R1 that day. S1 reported they remembered the day they assisted R1 in 2021. S1 reported staffing was difficult that day due to absences related to COVID-19 and they were asked to assist residents as needed. S1 reported they assisted residents including R1 with toileting or showering. S1 reported they had been a caregiver at another facility prior to their employment at Brookdale Murrieta and were familiar with the required duties. Additionally, S1 reported they had received extra training in the form of shadowing the caregivers upon being hired at Brookdale Murrieta. A review of S1’s staff record revealed proof of required training.
This agency has investigated the complaint alleging "Staff neglect resulted in resident sustaining a pressure injury" and "Unqualified staff caring for resident". We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5