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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426434
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:55:50 PM


Document Has Been Signed on 07/24/2023 01:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:BROOKDALE CORONAFACILITY NUMBER:
336426434
ADMINISTRATOR:BRITTNEY MARTINEZFACILITY TYPE:
740
ADDRESS:2005 KELLOGG AVETELEPHONE:
(951) 898-6991
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:60CENSUS: 42DATE:
07/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Brittney Martinez-AdministratorTIME COMPLETED:
02:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced case management visit following a Department Complaint Investigation on 6/11/2020, complaint control number 18-AS-20200605103755. During the investigation, the Department found that R1 was not provided with the care and services needed to meet R1 needs.

R1 was admitted to the facility in 2016. Physician assessment completed in 2019 indicates that R1 had dementia and a history of skin breakdown. Per additional records review and staff interviews, R1 needed assistance with all activities of daily living (ADLs) such as bathing, dressing, toileting, medication administration. R1 was also considered non-ambulatory and used a wheelchair for mobility.

On January 2, 2020, R1 sustained an injury to lower left shin while being transferred by staff from wheelchair to bed. First aid treatment was done. According to facility records, on January 21, 2020, a physician determined the injury as a Stage III pressure injury (wound). Referral was made for wound care. On January 30, 2020, R1 returned from physician’s office, and it was indicated that R1 was to see home health soon. When interviewed, facility staff reported being unaware if R1 was placed on home health for treatment of the wound. In addition, a review of facility records revealed no evidence to support that R1 received wound care from home health. As a result, it is determined that facility staff failed to ensure that R1 was provided with the care and services needed to meet R1 needs. From at least January 21, 2020, until February 5, 2020, when R1 was admitted to the hospital due to poor oral intake, R1 did not receive home health treatment as needed to meet R1 needs.

During today’s visit, one deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Brittney Martinez, along with a copy of LIC809D and the appeal rights.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/24/2023 01:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: BROOKDALE CORONA
FACILITY NUMBER: 336426434

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2023
Section Cited
CCR
87468.2(a)(4)

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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities: ...Residents in privately operated RCFEs shall have all of the following...rights: To care, supervision, & services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, & competency to meet their needs.
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The licensee has agreed to read regulation 87468.2 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed send documented proof that the facility staff has been trained on the..
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Based on interviews & records review, the licensee did not comply with the section cited above evidenced by not ensuring R1 received the care, supervision & services to meet their needs which poses an immediate health, safety, or personal rights risk to persons in care.
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proper steps to initiate home health services for the residents. POC is due by 7/25/2023.

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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: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
LIC809 (FAS) - (06/04)
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