336426434-8-26-2024-56-AS-RHSL-D8HTK2-20240826144714

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336426434
Report Date: 08/26/2024
Date Signed: 08/26/2024 02:51:02 PM

Document Has Been Signed on 08/26/2024 02:51 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BROOKDALE CORONA		FACILITY NUMBER:	336426434
ADMINISTRATOR:	BRITTNEY MARTINEZ		FACILITY TYPE:	740
ADDRESS:	2005 KELLOGG AVE		TELEPHONE:	(951) 898-6991
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY:	60	CENSUS: 36	DATE:	08/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Executive Director, Btittney Martinez		TIME COMPLETED:	02:50 PM

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	On 08/26/2024 at 09:24 AM, Licensing Program Analysts (LPAs) Renese Howell-Small, Raquel Hernandez and Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs Howell-Small, Hernandez and Brown met with a staff and was granted entry to the facility. Executive Director (ED) Brittney Martinez was informed of the visit and met with LPAs Howell-Small, Hernandez and Brown. At the time of the visit there were twelve(12) staff present, and thirty-six (36) residents present. The facility is a fourty-five (45) bedroom, fourty-five bathrooms (45) bathrooms with a kitchen/dining area, living room/activity room. The facility is a Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of sixty (60) non-ambulatory residents and with approved hospice waiver for twelve (12) and the current census is thirty-six (36) residents. LPAs Howell-Small, Hernandez and Brown were accompanied by ED Martinez to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 71 degrees Fahrenheit. LPAs Howell-Small, Hernandez and Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs Howell-Small, Hernandez and Brown observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating combined smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, ombudsman poster, labor laws, and the disaster plan were posted in a common area. *Continuation in LIC809C *

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-Small	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: BROOKDALE CORONA	FACILITY NUMBER: 336426434
	VISIT DATE: 08/26/2024

NARRATIVE

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LPA's Howell-Small, Hernandez and Brown tested the pull cord on 08/26/24 at 11:23AM in Resident's room#5 and waited for ten minutes. LPA's observed that the pull cord is in disrepair. Deficiency will be issued.

Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Room with the resident’s medications locked. LPAs Howell-Small, Hernandez and Brown observed complete first aid kit but no first aid book maintained at the facility. A deficiency will be issued.

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than three (3) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. All kitchen staff have their updated ServSafe Certification and Food Handlers’ card.

Care & Supervision: The facility has an Executive Director present in the facility with appropriate and enough hours to effectively manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA's Howell-Small, Hernandez and Brown reviewed five (5) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA's Howell-Small, Hernandez and Brown observed resident files reviewed were complete. LPA's Howell-Small, Hernandez and Brown reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA's Howell-Small, Hernandez, Brown observed that files reviewed were complete. However, during medications audit, LPA's Howell-Small, Hernandez and Brown observed Resident #8 (R8) three (3) medications were not given according to R8 physician's directions, as evidenced of the 3 medications were observed to be missing in the medication room. Also, two (2) of Resident#9 (R9) medications were observed to be missing in the medication room. A deficiency will be issued.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D forms, and Appeal Rights were discussed and provided to Executive Director Brittney Martinez.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-Small	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/26/2024 02:51 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROOKDALE CORONA	FACILITY NUMBER: 336426434
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(i)(1)(A)

Maintenance and Operation

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and records review, the licensee did not comply with the section cited above by not ensuring that the signal system is operating in resident's living unit as evidenced of room 5 signal system/pull cord was not working during the facility visit, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	Licensee fixed the signal system/pull cord during the visit. Plan of Correction (POC) cleared.

Type A

Section Cited

CCR

87465(a)(8)(A)

Incidental Medical and Dental Care Services

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency is maintained at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	Licensee stated to obtain or purchase a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency and submit proof to LPA Howell-Small by the POC due date.

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: Karen Clemons	TELEPHONE: (951) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-Small	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 08/26/2024 02:51 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROOKDALE CORONA	FACILITY NUMBER: 336426434
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #8 (R8) three (3) medications were given according to R8 physician's directions, as evidenced of the 3 medications were observed to be missing in the medication room and two (2) of Resident#9 (R9) medications were observed to be missing in the medication room and R9's medications were not given per R9's physicians directions, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87465(c)(2) and submit proof to LPA Howell-Small by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Karen Clemons	TELEPHONE: (951) 836-2748
LICENSING EVALUATOR NAME: Renese Howell-Small	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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