366402583-6-27-2023-56-AS-EMAN-CTASSP-20230630140816

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366402583
Report Date: 06/27/2023
Date Signed: 06/27/2023 11:01:16 AM

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
06/05/2023 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230605105734

FACILITY NAME:	BROOKDALE NORTH EUCLID		FACILITY NUMBER:	366402583
ADMINISTRATOR:	EMELIE R. FRANCO		FACILITY TYPE:	740
ADDRESS:	1031 N EUCLID AVE		TELEPHONE:	(909) 391-2622
CITY:	ONTARIO	STATE: CA	ZIP CODE:	91762
CAPACITY:	140	CENSUS: 70	DATE:	06/27/2023
		ANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	District Director of Operations Luis Rodriguez		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Resident sustained burn injury while in care
Staffs did not report unusual incident to resident's POA
Staffs do not assist resident with incontinence needs

INVESTIGATION FINDINGS:

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On 06/27/2023 at 10:15 AM, Licensing Program Analyst (LPA) Melody Brown met with District Director of Operations Luis Rodriguez at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegations. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of observation and interviews with relevant parties. The first allegation indicates that Resident sustained burn injury while in care. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents indicated that there's no resident at the facility that sustained burn injury while in care. Resident #1 (R1) reported to LPA Brown that R1 did not sustain burn injury.Staffs interviews indicated that no residents at the facility sustained burn injuries while in their care.
*** Continuation in LIC9099C ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

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-20230605105734

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: 06/27/2023

NARRATIVE

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The second allegation indicates Staffs did not report unusual incident to resident's POA. Residents interviews indicated that staffs at the facility are reporting unusual incidents to residents family, responsible party or Power of Attorney (POA). Staffs interviews revealed that the facility has proper procedure in place on reporting unusual incident report to residents family, responsible party or Power of Attorney (POA) and there's no incident that happened at the facility that a staff did not report a resident unusual incident to residents' POA.

The third allegation indicates Staffs do not assist resident with incontinence needs. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents indicated that staffs are assisting residents with incontinence needs, Residents reported that staffs are checking on them if they needed to be changed three (3) to four (4) times per day. Staffs interviews indicated that they are assisting residents with incontinence needs. Staffs interviews revealed 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 residents. Staffs interviews indicated that there's no incident that happened at the facility that a staff did not assist a resident with incontinence needs.

Based on interviews and records review, the allegation Resident sustained burn injury while in care (Allegation #1), Staffs did not report unusual incident to resident's POA (Allegation #2), and Staffs do not assist resident with incontinence needs (Allegation #3) 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 District Director of Operations Luis Rodriguez.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC9099 (FAS) - (06/04)

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