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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426434
Report Date: 05/25/2022
Date Signed: 05/25/2022 04:15:54 PM


Document Has Been Signed on 05/25/2022 04:15 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:BROOKDALE CORONAFACILITY NUMBER:
336426434
ADMINISTRATOR:MARITZA LUJANFACILITY TYPE:
740
ADDRESS:2005 KELLOGG AVETELEPHONE:
(951) 898-6991
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:60CENSUS: 45DATE:
05/25/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Business Office Coordinator, Jennifer LazaroTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Jennifer Semin conducted a case management in conjunction with complaint control number 18-AS-20200629144235. LPA met with Business Office Coordinator, Jennifer Lazaro.

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.


This requirement was not met as evidence by: LPA requested to review Resident 1's (R1's) file. LPA noted several entries that met the criteria for the facility to complete and submit a special incident report (SIR) to licensing. The facility did not submit an SIR for the incidents. This poses a potential risk to residents in care.
A deficiency will be cited.
An exit interview was conducted where this report, LIC809D, and appeal rights were discussed and provided to Ms. Lazaro.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
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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Document Has Been Signed on 05/25/2022 04:15 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: BROOKDALE CORONA
FACILITY NUMBER: 336426434

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2022
Section Cited

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Reporting Requirements: A written report shall be submitted to the licensing agency & to the person responsible for the resident within seven days of the occurrence of....Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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This requierment was not met as evidence by: LPA requested to review Resident 1's (R1's) file. LPA noted several entries that met the criteria for the facility to complete and submit a special incident report (SIR) to licensing. The facility did not submit an SIR for the incidents. This poses a potential risk to residents in care.
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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) 202-6356
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
LIC809 (FAS) - (06/04)
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