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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366402583
Report Date: 06/20/2023
Date Signed: 06/20/2023 12:42:33 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, 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
08/02/2022 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220802112321
FACILITY NAME:BROOKDALE NORTH EUCLIDFACILITY NUMBER:
366402583
ADMINISTRATOR:LISA TOFACILITY TYPE:
740
ADDRESS:1031 N EUCLID AVETELEPHONE:
(909) 391-2622
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY:140CENSUS: 70DATE:
06/20/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Executive Director Lisa ToTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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9
Staff are not performing services as specified in the admission agreement
Facility is charging for extra services not accorded to resident
Facility did not evaluate resident needs during pre-admission
Facility electrical wiring is in disrepair
Facility denied visitors entry to visit residents
Staff are not providing medication assistance
Staff are not assisting residents with incontinence care
Staff are not assisting residents with bathing
Staff do not respond to call button alerts
Staff do not ensure resident rooms are kept clean
INVESTIGATION FINDINGS:
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On 06/20/2023 at 11:30 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to deliver the findings on the complaint allegations listed above. LPA Brown was greeted and granted entrance to the facility by a staff and Executive Director Lisa To met with LPA Brown. LPA Brown explained the purpose of the visit.

The investigation was conducted by LPA Melody Brown. The investigation consisted of observations, records review and interviews with relevant parties. The first allegation indicates that Staff are not performing services as specified in the admission agreement. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with staffs and residents indicated that staffs at the facility performs or provides services as specified in the admission agreement. Staff interviews revealed that what's really happening is that the staffs at the facility are providing additional services to Resident #1 (R1) that are not specified in the Admission Agreement for R1 because R1's very particular of what R1 likes at the facility.
***Conrinuation in LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
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 4
Control Number 56-AS-20220802112321
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 NORTH EUCLID
FACILITY NUMBER: 366402583
VISIT DATE: 06/20/2023
NARRATIVE
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The second allegation indicates Facility is charging for extra services not accorded to resident. Interviews with residents indicated that the facility is not charging extra services not accorded to resident and they were never aware of an incident that happened at the facility that the facility charge extra services not accorded to resident. Interviews with staffs also indicated that the facility is not charging extra services not accorded to residents. Moreover, staffs interviews revealed that what's really happening at the facility is that the staffs are providing additional services to Resident #1 (R1) because R1's very particular of what R1 likes at the facility and the staffs wants R1 to be happy at the facility.

The third allegation indicates Facility did not evaluate resident needs during pre-admission. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents indicated that staffs at the facility evaluated their needs and completed a Pre-Admission Appraisal upon moving in at the facility. Staffs interviews revealed that the facility evaluates all residents needs during pre-admission and it's completed by either the Executive Director or the facility nurses. During the visit last 06/13/2023, LPA Brown reviewed R1 facility records and obtained R1's Pre-Admission Appraisal.

The fourth allegation indicates Facility electrical wiring is in disrepair. Residents interviews indicated that the facility electrical wiring is not in disrepair and resident interviews also revealed that there's no broken electrical sockets in their bedrooms. Staffs interviews indicated that the facility's electrical wiring is not in disrepair and staffs interviews revealed that if a residents' electrical socket's broken due to a resident pulling their electronic charger, the broken electrical socket will be repaired the same day but there's no incident that happened at the facility that the facility's electrical wiring is in disrepair.

The fifth allegation indicates Facility denied visitors entry to visit residents. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents indicated that the facility never denied their visitors entry to the facility to visit them and even during the time that there was power outage at the facility, their visitors were never denied entry at the facility to visit them. Interviews with staffs indicated that visitors at the facility are allowed entry 24 hours and they never denied any visitors entry to visit residents even when there was a power outage at the facility.

*** Continuation in LIC9099C ***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20220802112321
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 NORTH EUCLID
FACILITY NUMBER: 366402583
VISIT DATE: 06/20/2023
NARRATIVE
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The sixth allegation indicates Staff are not providing medication assistance. Interviews with residents indicated that Medical Technician (MedTech) staffs at the facility are providing medication assistance to the residents with medication management services and there's no incident that happened at the facility that a staff did not provide a medication assistance to a resident with medication management services. Staffs interviews revealed that MedTech staffs are providing medication assistance to residents with medication management services and there's no incident happened at the facility that a MedTech staff did not provide medication assistance to a resident with medication management services.

The seventh allegation indicates Staff are not assisting residents with incontinence care. Interviews with residents indicated that staffs at the facility are assisting residents with incontinence care. During the interview, residents reported to LPA Brown that staffs checked on them every two (2), three (3) or four (4) hours to determine if they needed to be changed. Staffs interviews revealed that all staffs are working together to assist resident with incontinence care and they added that they are checking on their residents every two (2) hours, three (3) hours or sometimes more frequently as it depends on the care plan of the resident. Staffs interviews indicated that there's no incident that happened at the facility that a staff did not assist a resident with incontinence care.

The eight allegation indicates Staff are not assisting residents with bathing. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents indicated that staffs at the facility are assisting residents with bathing. Interviews with residents revealed that all residents have their shower schedule of two (2) showers per week and there's no incident happened at the facility that a staff did not assist a resident with bathing. Staffs interviews indicated that they are assisting residents with bathing and there's no incident that happened at the facility that a staff did not assist a resident with bathing unless a resident refused to shower or bath.

The ninth allegation indicates Staff do not respond to call button alerts. Interviews with residents indicated that staffs always responds to call button alerts in ten (10) to fifteen (15) minutes and there's no incident that happened at the facility that a staff did not respond to call button alerts. Staffs interviews indicated that they all respond to call button alerts and there's no incident happened at the facility that a staff did not respond to a call button alert because all call button alerts are always answered by a staff at the facility.

*** Continuation in LIC9099C ***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 56-AS-20220802112321
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 NORTH EUCLID
FACILITY NUMBER: 366402583
VISIT DATE: 06/20/2023
NARRATIVE
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The tenth allegation indicates Staff do not ensure resident rooms are kept clean. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents indicated that staffs at the facility ensure that their rooms are kept clean. Residents interviews revealed that housekeeper cleans their room once per week and staffs are helping them maintain their room clean. Staffs interviews indicated all staffs at the facility are ensuring that residents room are kept clean and all of them are working together to maintain the cleanliness in each residents room. Staffs interviews revealed that there's no incident happened at the facility that staffs did not ensure that resident rooms are kept clean. During the visit last 05/12/2023 and 06/13/2023, LPA Brown observed residents' room clean.

Based on interviews and records review, the allegation Staff are not performing services as specified in the admission agreement (Allegation #1), Facility is charging for extra services not accorded to resident(Allegation #2), Facility did not evaluate resident needs during pre-admission (Allegation #3), Facility electrical wiring is in disrepair (Allegation #4), Facility denied visitors entry to visit residents (Allegation #5), Staff are not providing medication assistance (Allegation #6), Staff are not assisting residents with incontinence care (Allegation #7), Staff are not assisting residents with bathing (Allegation #8), Staff do not respond to call button alerts (Allegation #9), Staff do not ensure resident rooms are kept clean (Allegation #10) are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, where this report (LIC9099) was discussed and provided to Executive Director Lisa To.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4