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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426511
Report Date: 10/28/2020
Date Signed: 10/28/2020 05:14:04 PM



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
08/06/2020 and conducted by Evaluator Natalie Gayoso
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200806105920
FACILITY NAME:BROOKDALE MAGNOLIAFACILITY NUMBER:
336426511
ADMINISTRATOR:SARAH DEVOREFACILITY TYPE:
740
ADDRESS:737 MAGNOLIA AVETELEPHONE:
(951) 737-1600
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:180CENSUS: 137DATE:
10/28/2020
UNANNOUNCEDTIME BEGAN:
03:49 PM
MET WITH:Mary McClureTIME COMPLETED:
04:40 PM
ALLEGATION(S):
1
2
3
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5
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9
Resident not administered medication as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Natalie Gayoso conducted a tele-visit via telephone due to COVID-19 to deliver findings for the above allegations. LPA identified herself and discussed the purpose of the call with Administrator Mary McClure.

The investigation consisted of interviews and records review. The allegation indicated resident not administered medication as prescribed. Interview with Resident 1 (R1) revealed R1 is able to self administer medication and only needed assistance for a week with medication. R1 stated the facility never missed administrating medication. A review of R1's medication administration record revealed that the facility administered R1's medications as per physicians orders. Based on interview and records review, resident not administered medication as prescribed is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
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-20200806105920
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 MAGNOLIA
FACILITY NUMBER: 336426511
VISIT DATE: 10/28/2020
NARRATIVE
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Based on LPA interviews which were conducted, and records review, the allegations is unsubstantiated. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies were cited at this time. An exit interview was conducted, and a copy of this report was reviewed and provided to the administrator via email.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Natalie GayosoTELEPHONE: (951) 290-1102
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2