366402583-10-10-2024-56-AS-EMAN-DABRXL-20241023132455

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366402583
Report Date: 10/10/2024
Date Signed: 10/10/2024 12:46:52 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
10/04/2024 and conducted by Evaluator Raquel Hernandez

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20241004171919

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: 66	DATE:	10/10/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Executive Director Lisa To		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility restroom lights on timer turned off resulting in a fall to resident

INVESTIGATION FINDINGS:

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On 10/09/2024 Licensing Program Analysts (LPAs) Raquel Hernandez and Mary Rico conducted an unannounced visit to deliver findings on the allegation listed above. LPAs met with Administrator Lisa To and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews and facility tour.

For the allegation, Facility restroom lights on timer turned off resulting in a fall to resident.

LPA Hernandez conducted (5) resident interviews and (5) staff interviews. During resident interviews (5) out of the (5) residents stated staff comes when help pendant is pressed or pull cord is pulled. Additionally, (5) out of the (5) residents stated to not having any issues or falls within the public bathroom. Moreover, (5) out of the (5) staff interviewed stated no residents at facility have had any issues with public bathrooms and with their help pendant and pull cord.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Raquel Hernandez	TELEPHONE: 951-248-0336
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

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 56-AS-20241004171919

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROOKDALE NORTH EUCLID	FACILITY NUMBER: 366402583
	VISIT DATE: 10/10/2024

NARRATIVE

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During facility tour, LPAs Hernandez and Rico observed upstairs men and women public bathroom. Both bathrooms are motion censored and have a light switch to turn off and on the light. Additionally, both bathrooms pull cords are working. LPAs tested residents help pendants and pull cord and verified equipment is working.

During record review, LPAs received a copy of LIC624. LPAs verified facility followed the right protocols to ensure the residents safety.

Based on the evidence gathered during today’s investigation, the allegation listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

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 (LIC9099) was discussed and provided to Administrator Lisa To.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Raquel Hernandez	TELEPHONE: 951-248-0336
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC9099 (FAS) - (06/04)

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