336426434-7-28-2023-18-AS-EMAN-CU9MGG-20230731093555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426434
Report Date: 07/28/2023
Date Signed: 07/28/2023 10:53:52 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
06/05/2020 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200605103755

FACILITY NAME:	BROOKDALE CORONA		FACILITY NUMBER:	336426434
ADMINISTRATOR:	CAROL ANN LEROSE		FACILITY TYPE:	740
ADDRESS:	2005 KELLOGG AVE		TELEPHONE:	(951) 898-6991
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY:	60	CENSUS: 41	DATE:	07/28/2023
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Brittney Martinez- Administrator		TIME COMPLETED:	11:03 AM

ALLEGATION(S):

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Facility staff did not provide resident's authorized representative with copies of resident's records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to issue findings for the allegation listed above. LPA stated the purpose of the visit and was granted entry and met with Administrator Brittney Martinez. The investigation consisted of staff interviews and document review.

For allegation, Facility staff did not provide resident's authorized representative with copies of resident's records:

Document review and interviews with staff revealed that the individual requesting copies of the resident’s records was not the primary individual listed on the resident’s legal durable power of attorney. The facility was not legally authorized to release documents to the individual that was requesting the resident’s records. The facility was not legally authorized to release documents to the secondary individual listed on the durable power of attorney due to the status of the primary individual.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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 18-AS-20200605103755

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 07/28/2023

NARRATIVE

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Based on evidence obtained during the investigation, the allegation listed above is deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Brittney Martinez, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC9099 (FAS) - (06/04)

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