366402583-2-26-2024-56-AS-MBRN-D2TSQ8-20240226130418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366402583
Report Date: 02/26/2024
Date Signed: 02/26/2024 01:04:34 PM

Document Has Been Signed on 02/26/2024 01:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

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:	02/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Executive Director Lisa To		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 02/26/2024 at 9:30 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff at the reception area, and was granted entry to the facility. Executive Director Lisa To was contacted and met with LPA Brown. At the time of the visit there were five (5) direct care staffs present, and sixty-six (66) residents present. The facility is a ninety-seven (97) rooms, one hundred and three (103) bathrooms with a kitchen/dining area, and living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of one hundred forty (140) non-ambulatory residents, approved for ten (10) hospice waivers and five (5) bedridden. The current census is sixty-six (66) residents. LPA Brown was accompanied by Business Office Manager Marcos Ramos to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperature in a resident bathroom to be at 106 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster, labor laws, and the disaster plan were posted in a common area. *Continuation in LIC809C *

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 NORTH EUCLID	FACILITY NUMBER: 366402583
	VISIT DATE: 02/26/2024

NARRATIVE

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Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Room with the resident’s medications locked. LPA Brown observed the complete first aid kit and first aid book/manual at the facility.

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. All kitchen staffs have their updated ServSafe Certification and food handlers’ card.

Care & Supervision: The facility has an Executive Director present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA Brown reviewed four (4) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Brown observed resident files reviewed were complete. LPA Brown reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) Test Result. LPA Brown observed that staff files reviewed were complete. Medications/Medication Administration Record (MAR) were audited for four (4) residents, and LPA Brown observed no issue.

Based on the observations made during today’s visit, no deficiencies nor advisories issued per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), was discussed and provided to Executive Director Lisa To.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC809 (FAS) - (06/04)

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