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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881034
Report Date: 04/28/2023
Date Signed: 04/28/2023 01:15:21 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
04/13/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230413134644
FACILITY NAME:BROOKDALE LOMA LINDAFACILITY NUMBER:
361881034
ADMINISTRATOR:LUJAN, MARITZAFACILITY TYPE:
740
ADDRESS:25585 VAN LEUVEN STREETTELEPHONE:
(909) 796-5421
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:220CENSUS: 105DATE:
04/28/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Ashley Fife, Business Office ManagerTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff do not keep facility kitchen clean and sanitary
Facility kitchen has mold
INVESTIGATION FINDINGS:
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On 4/28/23, Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit at the facility. LPA met with Ashley Fife, Business Office Manager and discussed the purpose of the visit.

Regarding the allegation, staff do not keep facility kitchen clean and sanitary, LPA toured the kitchen, which was accessible and free of litter. All staff in the kitchen were wearing hair coverings. Kitchen equipment, dishes and utensils were clean. Procedures necessary for proper cleaning, sanitizing dishes and hand washing were posted in the kitchen area. All residents interviewed stated that they have not observed staff not keeping the kitchen clean nor have they seen dirty trays when being served meals. All staff interviewed deny kitchen not clean and sanitary.

Regarding the allegation, facility kitchen has mold, LPA toured the kitchen and did not observe mold. All residents interviewed have not observed mold in kitchen. All staff interviewed have not observed mold in the kitchen.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
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 4
Control Number 56-AS-20230413134644
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 LOMA LINDA
FACILITY NUMBER: 361881034
VISIT DATE: 04/28/2023
NARRATIVE
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Based on observations, staff and resident interviews, and document review, the above allegation(s) are Unsubstantiated. A finding of unsubstantiated means 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.

An exit interview was conducted where this report was discussed and a copy of this report with appeal rights was provided to the Business Office Manager at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
04/13/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230413134644

FACILITY NAME:BROOKDALE LOMA LINDAFACILITY NUMBER:
361881034
ADMINISTRATOR:LUJAN, MARITZAFACILITY TYPE:
740
ADDRESS:25585 VAN LEUVEN STREETTELEPHONE:
(909) 796-5421
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:220CENSUS: 105DATE:
04/28/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Ashley Fife, Business Office ManagerTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff do not properly store food
INVESTIGATION FINDINGS:
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On 4/28/23, Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit at the facility. LPA met with Ashley Fife, Business Office Manager and discussed the purpose of the visit.
Regarding the allegation that staff do not properly store food, LPA observed in the kitchen freezer/refrigerator the following: plates with cake and plates with salad that were not covered; single serving, sauce containers on a tray that were not covered, and a container of strawberries that was open and unprotected from contamination.

Based on observations, the perponderance of evidence has been met, therefore the above allegations (s) is found to be Substantiated. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D.

A Plan of Correction was reviewed and developed by the Licensee/Administrator Marlin Fish . An exit
interview was conducted at the conclusion of the visit and a copy of reports (LIC9099-A & LIC9099-D) with appeal rights was provided to the Business Office Manager.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20230413134644
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 LOMA LINDA
FACILITY NUMBER: 361881034
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2023
Section Cited
CCR
87555(b)(23)
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87555 General Food Service(b)
the following food...requirements shall apply(23)All readily perishable foods ...capable of supporting rapid and...growth of micro-organisms which can cause food infections...shall be stored in covered containers...This requirement is not met by:
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Licensee/Administrator is to discard any left over perishable iitems from previous meals and and ensure all perishable items are store and covered. Licensee/Administrator to read and conduct training on the cited regulation and submit proof to to CCLD by POC date
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LPA observed food on plates and sauces in containers, and package of strawberries in freezer/refrigerator that were not covered; which poses a potentional health, safety and personal rights 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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4