366402583-4-26-2021-18-AS-NBRN-C2KUTN-20210430155211

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366402583
Report Date: 04/26/2021
Date Signed: 04/26/2021 11:42:31 AM

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
04/14/2020 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200414130259

FACILITY NAME:	BROOKDALE NORTH EUCLID		FACILITY NUMBER:	366402583
ADMINISTRATOR:	LISA TO		FACILITY TYPE:	740
ADDRESS:	1031 N EUCLID AVE		TELEPHONE:	(909) 391-2622
CITY:	ONTARIO	STATE: CA	ZIP CODE:	91762
CAPACITY:	140	CENSUS: 58	DATE:	04/26/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Lisa To, Executive Director		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff are vaping in the facility kitchen.

INVESTIGATION FINDINGS:

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Amy Goldenberg, Licensing Program Analyst (LPA), is conducting a visit to conclude this agency’s investigation into the complaint allegation mentioned above. This visit was conducted telephonically with Executive Director Lisa To as a COVID 19 related precautionary measure.

During this investigation two interviews were conducted. LPA reviewed one employee file (S1) and obtained one corrective action letter dated 04/13/2020. LPA received and reviewed ECOLAB service agreement and customer service reports. LPA additionally reviewed the facility record for relevant information.

In regard to the allegation that staff are vaping in the kitchen LPA learned the following:

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021

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 18-AS-20200414130259

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 NORTH EUCLID	FACILITY NUMBER: 366402583
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/26/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/26/2021 Section Cited CCR 87208(a)	1 2 3 4 5 6 7	Plan of Operation: Each facility shall have and maintain a current, written definitive plan of operation. The facility staff did not maintain this regulatory requirement as evidenced by S1 violating facility	1 2 3 4 5 6 7	This POC was executed on 04/13/2020 with the termination of S1 on 04/13/2020. POC is cleared.
	8 9 10 11 12 13 14	Smoke-Free environment when video evidence revealed vaping in the kitchen. This poses a risk to the health and safety of others in the facility.	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: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 18-AS-20200414130259

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 NORTH EUCLID	FACILITY NUMBER: 366402583
	VISIT DATE: 04/26/2021

NARRATIVE

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On page 57 of the Associate Handbook provided to all employees describes a smoke-free environment which included the use of electronic devices that produce a nicotine vapor. On 04/10/2020, the community received video evidence showing S1 vaping in the kitchen. S1 was terminated from employment on 04/13/2020 for smoking or use of a tobacco product at an unauthorized time or in an unauthorized location.

We have substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative via email.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021

LIC9099 (FAS) - (06/04)

Page: 3 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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2020 and conducted by Evaluator Amy Goldenberg

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200414130259

FACILITY NAME:	BROOKDALE NORTH EUCLID		FACILITY NUMBER:	366402583
ADMINISTRATOR:	LISA TO		FACILITY TYPE:	740
ADDRESS:	1031 N EUCLID AVE		TELEPHONE:	(909) 391-2622
CITY:	ONTARIO	STATE: CA	ZIP CODE:	91762
CAPACITY:	140	CENSUS: 58	DATE:	04/26/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Lisa To, Executive Director		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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9

The facility is not addressing pest control effectively.

INVESTIGATION FINDINGS:

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12
13

Amy Goldenberg, Licensing Program Analyst (LPA), is conducting a visit to conclude this agency’s investigation into the complaint allegation mentioned above. This visit was conducted telephonically with Ececutive Director Lisa To as a COVID 19 related precautionary measure.

During this investigation two interviews were conducted. LPA reviewed one employee file (S1) and obtained one corrective action letter dated 04/13/2020. LPA received and reviewed ECOLAB service agreement and customer service reports. LPA additionally reviewed the facility record for relevant information.

In regard to the allegation the facility is not addressing pest control effectively, LPA learned the following:

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 18-AS-20200414130259

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 NORTH EUCLID	FACILITY NUMBER: 366402583
	VISIT DATE: 04/26/2021

NARRATIVE

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Review of the facility file revealed that the allegation "the facility is infested with rodents" was investigated and substantiated 12/18/2019. The facility at that time submitted a plan of correction that was accepted by CCL and cleared. The facility as a result changed pest control companies and obtained a service agreement with ECOLAB to address all of the pest control concerns. Customer service reports reviewed support as evidence that the facility has maintained their pest control contract and effectively are addressing any pest control issues on an ongoing basis with a professional pest control company.

We have found the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. A copy of this report is being reviewed with, and furnished to the facility representative via email.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Amy Goldenberg	TELEPHONE: (951) 248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5