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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402583
Report Date: 02/07/2024
Date Signed: 02/07/2024 11:36:52 AM


Document Has Been Signed on 02/07/2024 11:36 AM - 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 EUCLIDFACILITY NUMBER:
366402583
ADMINISTRATOR:LISA TOFACILITY TYPE:
740
ADDRESS:1031 N EUCLID AVETELEPHONE:
(909) 391-2622
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY:140CENSUS: 67DATE:
02/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Executive Director Lisa ToTIME COMPLETED:
11:45 AM
NARRATIVE
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On 02/07/2024 at 09:05 AM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to initiate a Case Management visit. LPA Brown was greeted and granted entry by a staff at the reception area and Executive Director (ED) Lisa To was contacted and informed of the visit. LPA Brown explained the purpose of the visit to ED To. The investigation consisted of observation, interviews, and a review of pertinent documentation.

During the tour of the facility on 07/13/2023, LPA Brown observed the half bed rails on Resident #1 (R1) and Resident #5 (R5) and staff interview and records review revealed no written order from R1 and R5 physician indicating the need for the postural support maintained in R1 and R5 facility record when they moved in at the facility on 01/31/2023. Staff #1 (S1) confirmed to LPA Brown that R1 and R5 moved in at the facility with their bed rails and their doctor's written order indicating the need for postural support were obtained around 07/2023, months after they already moved in at the facility. LPA Brown informed ED To that deficiency will be issued as this poses potential health, and safety risk to residents in care.

An exit interview was conducted where this report LIC809, LIC809D and Appeal Rights were 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: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
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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Document Has Been Signed on 02/07/2024 11:36 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/16/2024
Section Cited
CCR
87608(a)(3)

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87608 Postural Supports (a) Based on the individuals preadmission appraisal....(3) A written order from a physician indicating the need for the postural support shall be maintained in the residents record. The licensing agency... This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87608(a)(3) and submit proof of All Staff Training Log to LPA Brown at Plan of Correction (POC) due date.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by having Resident #1 (R1) and Resident #5 (R5) half bed rail with no written order from R1 and R5 physician indicating the need for the postural support maintained in R1 and R5 facility record upon moving in at the facility on 01/31/2023 which poses a potential health, safety or personal rights risk to residents in care.
The Licensee stated to submit written order from R3's physician indicating the need for the postural
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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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
LIC809 (FAS) - (06/04)
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