361881034-2-15-2024-18-AS-JDHS-D2WQZN-20240229113700

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361881034
Report Date: 02/15/2024
Date Signed: 02/15/2024 05:16:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/30/2021 and conducted by Evaluator Yolanda Delgado

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210730133208

FACILITY NAME:	BROOKDALE LOMA LINDA		FACILITY NUMBER:	361881034
ADMINISTRATOR:	ADAMS, LUCINDA		FACILITY TYPE:	740
ADDRESS:	25585 VAN LEUVEN STREET		TELEPHONE:	(909) 796-5421
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	220	CENSUS: 107	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Maritza Lujan, Administrator		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Facility staff did not ensure that resident's medication was refilled in a timely manner
Facility staff failed to report changes to resident's POA
Facility charging resident for additional services

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Yolanda Delgado made an unannounced visit to the facility to deliver findings for a complaint investigation into the allegations listed above. During the investigation, LPA interviewed four (4) staff members and eight (8) residents. LPA reviewed pertinent documents pertaining to the allegations. LPA was unable to interview pertinent residents due to refusal.
On July 30, 2021, Community Care Licensing received a complaint indicating facility staff did not ensure that resident’s medication was refilled in a timely manner, facility staff failed to report changes to resident’s Power of Attorney, and facility was charging resident for additional services.

(continued on page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20210730133208

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BROOKDALE LOMA LINDA	FACILITY NUMBER: 361881034
	VISIT DATE: 02/15/2024

NARRATIVE

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In regards to the allegation that facility staff did not ensure resident’s medication was refilled in a timely manner, Resident #1 (R1)’s POA stated the facility ran out of R1’s anxiety medication and didn’t notify POA. On May 14, 2022, It was also advised that Resident #2 (R2) medications were running low. LPA conducted interviews with Staff #1 (S1), #2 (S2), #3 (S3), #4 (S4) and information obtained from staff interviews reveal that medications were refilled in a timely manner by staff. Interview with Resident #3 (R3) revealed that medications have been refilled in a timely manner by family members, resident preferred pharmacy and residents R4, R6, R7, R8 not on the medication management program. LPA reviewed R1 and R2’S admissions agreement and the care plan revealed that the facility would order and coordinate medications between the family, health care providers and pharmacy. R1 & R2’s responsible party would refill the medication and bring to the facility. The facility would provide attention and/or assistance with taking medications, assist with medication storage.
In regards to the allegation that the facility staff failed to report changes to resident’s Power of Attorney. It was reported that Resident #1 (R1)’s had a prescription change for medication and the facility did not notify the Power of Attorney. LPA conducted interviews with Staff #1, #2 (S2), #3 (S3), #4 (S4) and information obtained from staff interviews did not reveal that staff failed to report changes to resident’s Power of Attorney. Interviews with Resident #3 (R3), R4, R5, R6, R7, R8, R9 revealed that if there were any changes of condition and care for residents, Power of Attorney would be notified. R1’s Medication Administration Records for April 2021, May 2021, June 2021 and July 2021 did not reveal changes in medications.
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SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 18-AS-20210730133208

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BROOKDALE LOMA LINDA	FACILITY NUMBER: 361881034
	VISIT DATE: 02/15/2024

NARRATIVE

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In regards to the allegation that the facility was charging resident for additional services. It was reported that R1 was paying extra for Medication Management that includes order and coordinate medications between the family, health care providers and pharmacy, the facility would provide attention and/or assistance with taking medications, assist with medication storage. On May 31, 2022, it was reported that R2 is paying extra for medication management. LPA conducted interviews with Resident #1 (R1), #2 (R2), R4, R5, R6, R7, R8, R9 and the interviews revealed that R1, R2, and R3 are on a medication management program and R1 and R2’s admission agreements and assessment summary observed the fees and the medication management services are being provided to R1 and R2. Interviews conducted with staff revealed that the facility provided medication management services and there is a fee.
Based on interviews conducted and observations, the preponderance of evidence standard has not been met. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegations is unsubstantiated.
An exit interview was conducted, and a copy of this report was provided along with LIC811 – Confidential Names List.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC9099 (FAS) - (06/04)

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