361881034-6-16-2022-56-AS-KCLS-CFTP4D-20220628105859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361881034
Report Date: 06/03/2022
Date Signed: 06/16/2022 12:46:21 PM

Unfounded

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2022 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220513164917

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: 112	DATE:	06/03/2022
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Maritza Lujan- Administrator		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Resident fell multiple times.
Staff handled resident in a rough manner.
Staff did not assess resident for injuries.
Staff are not checking on resident's.
Staff refused to provide resident with a new call pendant.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility for the purpose of initiating an investigation and delivering findings for the above complaint allegations.

LPA Gardner met with Administrator Maritza Lujan. At the time of visit there were fifty-three (53) staff and one hundred twelve (112) residents present.

LPA Gardner toured the facility, interviewed four (4) staff members (S1, S2, S3, S4) and interviewed eight (8) residents (R2, R3, R4, R5, R6, R7, R8, R9). LPA Gardner interviewed one (1) resident (R1) on a collateral visit at an offsite location on a separate date. R1 had to be interviewed at a separate location due to being sent out of the facility.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022

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 5

Control Number 56-AS-20220513164917

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
, CA 92507

FACILITY NAME: BROOKDALE LOMA LINDA	FACILITY NUMBER: 361881034
	VISIT DATE: 06/03/2022

NARRATIVE

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For allegations, Resident fell multiple times, Staff handled resident in a rough manner, and Staff did not assess resident for injuries.

LPA Gardner found through record review that the resident in question was sent out of the facility on 5/1/2022 and has not returned to the facility. Due to the resident not being present in the facility on the dates that were in question, there is no evidence to support the allegations. Based on record review, the allegations are deemed to be UNFOUNDED.

For allegation, Staff are not checking on residents.

LPA Gardner found through interviews conducted with residents and staff that the staff does check on the residents. Based on interviews conducted, the allegation is deemed to be UNFOUNDED.

For allegation, Staff refused to provide resident with a new call pendant.

LPA Gardner found through record review that the facility ordered pendants on 4/25/2022. The pendants are on back order from the company. Administrator Maritza Lujan has contacted an alternative Brookdale facility and obtained additional pendants while waiting on the order to be delivered. Based on record review, the allegation is deemed to be UNFOUNDED.

A finding of UNFOUNDED, means that the allegations were false, could not have happened and/or is without a reasonable basis. Therefore, the complaints listed above are dismissed.

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 was discussed and provided to Administrator Maritza Lujan along with a copy of the appeal rights.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2022 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220513164917

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: 112	DATE:	06/03/2022
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Maritza Lujan- Administrator		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Staff are not responding to residents call buttons.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility for the purpose of initiating an investigation and delivering findings for the above complaint allegations. LPA Gardner met with Administrator Maritza Lujan. At the time of visit there were fifty-three (53) staff and one hundred twelve (112) residents present.

For allegation, Staff are not responding to residents call buttons.

LPA Gardner toured the facility, interviewed four (4) staff members (S1, S2, S3, S4) and interviewed eight (8) residents (R2, R3, R4, R5, R6, R7, R8, R9). LPA Gardner found through record review that during the dates of May 1, 2022 at 12:01 am and May 18, 2022 at 9:33 am, there were one hundred fifty-three (153) occurrences that took staff over an hour to respond to pendant calls.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022

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 5

Control Number 56-AS-20220513164917

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
, CA 92507

FACILITY NAME: BROOKDALE LOMA LINDA	FACILITY NUMBER: 361881034
	VISIT DATE: 06/03/2022

NARRATIVE

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Based on record review and interviews conducted the allegation is deemed SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Based on the record review, and interviews made 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 was discussed and provided to Administrator Maritza Lujan along with a copy of the appeal rights.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 56-AS-20220513164917

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
, CA 92507

FACILITY NAME: BROOKDALE LOMA LINDA	FACILITY NUMBER: 361881034
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/10/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements-General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.	1 2 3 4 5 6 7	The licensee has agreeed to read regulation 87411 entirely and send self-certify letter to LPA. Licensee has agreed to create a staffing plan that ensures staff is sufficient to respond to pendant calls.
	8 9 10 11 12 13 14	This requirement was not met based on evidence by interview and record review.The licensee did not comply with the section cited above by taking over an hour to respond to pendant calls, over an 18 day span, occurred 153 times, which poses an immediate health, safety, or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5