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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426434
Report Date: 07/28/2021
Date Signed: 07/28/2021 01:00:41 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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2021 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210723121639
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: DATE:
07/28/2021
UNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Maritza Lujan, Executive DirectorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Resident wandered away due to lack of supervision
INVESTIGATION FINDINGS:
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This unannounced visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is to initiate the 10 day visit to investigate the above mentioned complaint allegation. LPA met with Executive Director Maritza Lujan and discussed the elements of the allegation. During this investigation visit LPA tested exit doors, delayed egress, and received training material and attendance form for an elopement overview dated 07/21/2021. It is alleged that R1 left the facility unsupervised on 07/20/2021. Based on the information reported on 07/21/2021 by Maritza Lujan and information collected through witness interviews, it is confirmed that R1 left the community on 07/20/2021 unsupervised. We have substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence.

A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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 2
Control Number 18-AS-20210723121639
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
RIVERSIDE, CA 92507

FACILITY NAME: BROOKDALE CORONA
FACILITY NUMBER: 336426434
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2021
Section Cited
CCR
87705(j)
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The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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Facility administrator assessed exit and exit alarm systems and provided overview training on elopement to all staff. Door codes have been changed to limit user access.
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The facility has failed to meet this requirement as evidenced by R1 walking out of the facility without facility knowledge.
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When locked the front door with delayed egress and alarms are activated. There is to be a staff monitoring the lobby at all times.
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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: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2