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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426434
Report Date: 05/25/2022
Date Signed: 05/25/2022 04:01:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/29/2020 and conducted by Evaluator Jennifer Semin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200629144235
FACILITY NAME:BROOKDALE CORONAFACILITY NUMBER:
336426434
ADMINISTRATOR:CAROL ANN LEROSEFACILITY TYPE:
740
ADDRESS:2005 KELLOGG AVETELEPHONE:
(951) 898-6991
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:60CENSUS: 45DATE:
05/25/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Business Office Coordinator, Jennifer LazaroTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff failed to address resident's change in medical condition while in care
Staff failed to seek timely medical attention for resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Business Office Coordinator, Jennifer Lazaro

The investigation consisted of interviews and review of pertinent documents. Regarding the first allegation, Staff failed to address resident's change in medical condition while in care. Interviews with staff revealed that staff did address Resident 1’s (R1’s) change in condition by giving R1 their “as needed” medication. Medication Records indicate staff gave R1 their “as needed” medication but did not notify the facility nurse when the medication was ineffective. Staff interviews and facility records indicate that facility nurse did not notify R1’s physician or responsible party of R1’s change in condition.
Regarding the second allegation, Staff failed to seek timely medical attention for resident while in care. Interviews with staff revealed staff notified R1’s physician regarding R1’s change in condition. Documents indicated that Resident 1 (R1) moved into the facility on 6/18/2020 and on 6/29/2020 document indicate R1 had a change in condition, ongoing since 6/19/2020 and it was not brought to the attention of R1’s physician in a timely manner.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 18-AS-20200629144235
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/25/2022
NARRATIVE
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Based on interviews and documentation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099D, 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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20200629144235
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
05/26/2022
Section Cited
CCR
87466
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Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning & that appropriate assistance is provided when such observation reveals unmet needs. When changes such as..... a physical health condition are observed, the licensee
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Licensee shall read the regulation in it's entirety, submit a statement of understanding, train staff on this regulation and submit a training log to CCL by the POC due date of 5/26/2022.
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shall ensure that such changes are documented & brought to the attention of the resident's physician and the resident's responsible person, if any.This requirement was not met as evidenced by: Staff interviews and facility records indicate that facility nurse did not notify R1’s physician or responsible party of R1’s change in condition. This poses a risk to the health and safety of 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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20200629144235
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
05/26/2022
Section Cited
CCR
87705(b)(1)
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Care of Persons with Dementia: In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:
Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification,
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Licensee shall read the regulation in it's entirety, submit a statement of understanding, train staff on this regulation and submit a training log to CCL by the POC due date of 5/26/2022.
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and conservator, if any, when a resident’s behavior or condition changes. This regulation was not met as evidence by: Resident 1 had a change in condition, ongoing since 6/19/2020 and it was not brought to the attention of R1’s physician in a timely manner.This poses a health and safety 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
LIC9099 (FAS) - (06/04)
Page: 4 of 4