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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426434
Report Date: 03/08/2023
Date Signed: 03/08/2023 12:49:34 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
02/04/2021 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210204142306
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: 42DATE:
03/08/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jennifer Sanchez "Lazaro" - Business Office CoordinatorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident was left in soiled diapers for a prolonged time.
Resident's cane was taken away by facility staff.
Facility did not provide a copy of resident's records to responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to investigate and deliver findings for the above complaint allegations. LPA met with Business Office Coordinator Jennifer Sanchez "Lazaro" and explained the reason for the visit.

During today’s visit, LPA toured the facility, conducted interviews with staff and residents, reviewed and was provided facility documents.

For allegation, Resident was left in soiled diapers for a prolonged time:

During interviews with residents, LPA was informed that the residents’ diapers are changed as often as three (3) times a day, as well as more often as needed. LPA was not informed of a time when a resident was left in a soiled diaper for a prolonged time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
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 6
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
02/04/2021 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210204142306

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: 42DATE:
03/08/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jennifer Sanchez "Lazaro" - Business Office CoordinatorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Responsible party was not provided with a detailed explanation of the additional care services to be provided to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to investigate and deliver findings for the above complaint allegation. LPA met with Business Office Coordinator Jennifer Sanchez "Lazaro" and explained the reason for the visit.

During today’s visit, LPA toured the facility, conducted interviews with staff and residents, reviewed and was provided facility documents.

For allegation, Responsible party was not provided with a detailed explanation of the additional care services to be provided to resident:

During interviews with staff, LPA discovered the current staff was unsure if R1’s reappraisal/personal service plan dated 10/10/2020 was reviewed with R1’s responsible party. The staff that signed R1’s reappraisal/personal service plan dated 10/10/2020 does not work at the facility as of 8/7/2022.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20210204142306
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2023
Section Cited
CCR
87463(c)
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87463. Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months...
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The licensee has agreed to read regulation 87463 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to conduct a staff training to ensure residents reappraisal/personal service plan is reviewed with the resident and or their responsible party.
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Based record review, the licensee did not comply with the section cited above evidenced by reappraising and updating R1’s Personal Service plan on 10/10/2020 without informing R1’s responsible party of the changes which poses a potential health, safety, or personal rights risk to persons in care.
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The POC is due by 3/10/2023.
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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) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20210204142306
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: 03/08/2023
NARRATIVE
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During document review, LPA discovered that R1’s reappraisal/personal service plan was updated on 10/10/2020. The document was signed by a staff member but was not signed by R1’s responsible party. The facility did not provide LPA documented proof that the document was reviewed by R1’s responsible party.

Based on the evidence gathered during today’s investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of evidence the standard has been met.

During today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.
An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to Business Office Coordinator Jennifer Sanchez "Lazaro", along with a copy of the appeal rights.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20210204142306
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: 03/08/2023
NARRATIVE
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During interviews with staff, LPA discovered that staff check and change the residents’ diapers every one (1) to two (2) hours, as well as after each meal. If a resident soils more often, the resident will be changed more as needed.

For allegation, Resident's cane was taken away by facility staff:

During interviews with staff, LPA discovered that two (2) staff members remembered that R1 had times where they were aggressive with their cane. The staff remembered there was a conversation with R1’s responsible party about looking for an alternative option with R1’s doctor due to aggression. The staff could not recall R1’s cane being taken away by a staff.

During document review, LPA reviewed R1’s progress notes for November 2020, December 2020, January 2021, and February 2021. LPA discovered notes detailing aggressive behavior but did not find notes stating that a staff took away R1’s cane.


For allegation, Facility did not provide a copy of resident's records to responsible party:

During document review, LPA was shown a folder of R1’s documents with a note on it stating to give to resident’s responsible party. LPA was also shown an email communication dated 2/4/2021 to R1’s responsible party detailing the need to send a written request for R1’s documents. On 2/11/2021, an email was sent to R1’s responsible party detailing that R1’s documents were ready to be picked up at the facility.

During interview with staff, LPA discovered that R1’s documents were printed and set aside for R1’s responsible party, but they were never picked up.

Overall, LPA was not given information to collaborate the three (3) allegations listed above.

Based on the evidence found 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 violations did or did not occur.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20210204142306
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: 03/08/2023
NARRATIVE
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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 Business Office Coordinator Jennifer Sanchez "Lazaro", along with a copy of the appeal rights.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6