336426434-7-24-2023-18-AS-EMAN-CU9MGH-20230731093555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426434
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:49:20 PM

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: 42	DATE:	07/24/2023
		UNANNOUNCED	TIME BEGAN:	11:44 AM
MET WITH:	Brittney Martinez- Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff neglect resulted in resident's death.
Resident placed on hospice without proper authorization.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to deliver findings for the above complaint allegations that were initiated on 6/11/2020. LPA met with Administrator Brittney Martinez and explained the reason for the visit.

For allegation, Staff neglect resulted in resident’s death:

Interviews and record reviews conducted by the Department could not corroborate that R1 died as a result of staff neglect. It had been reported by facility staff that R1 was observed to have been declining in health for a short period of time prior to death. In addition, R1 was observed to be refusing to eat or drink. R1 was placed on hospice services on February 8, 2020, and subsequently passed away on February 12, 2020. Cause of death was indicated as Cerebral Vascular Disease.

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: 07/24/2023

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.

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: 07/24/2023

NARRATIVE

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For allegation, Resident placed on hospice without proper authorization:

Interviews and record reviews conducted by the Department could not corroborate that R1 was put on hospice without proper authorization. LPA reviewed R1’s physician’s order for hospice services dated 2/4/2020 signed by R1’s doctor. LPA also reviewed a document titled Notification of Initiation of Hospice Care Services, dated 2/10/2020 that authorized hospice services for R1 under the care of Brookdale Hospice. The document was acknowledged by R1’s power of attorney (POA). The staff stated that to initiate hospice services for a resident they are required to obtain a physician’s order and a signed statement from the resident’s POA. The facility completed both of these steps to ensure R1’s hospice needs were handled safely and correctly.

Based on evidence obtained during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are 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: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC9099 (FAS) - (06/04)

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