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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366402583
Report Date: 02/07/2024
Date Signed: 02/07/2024 11:32:22 AM

Substantiated


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
07/06/2023 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230706140934
FACILITY NAME:BROOKDALE NORTH EUCLIDFACILITY NUMBER:
366402583
ADMINISTRATOR:EMELIE R. FRANCOFACILITY TYPE:
740
ADDRESS:1031 N EUCLID AVETELEPHONE:
(909) 391-2622
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY:140CENSUS: 67DATE:
02/07/2024
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Executive Director Lisa ToTIME COMPLETED:
11:35 AM
ALLEGATION(S):
1
2
3
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5
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8
9
Staff are mismanaging residents medication.
Staff are charging residents for services not rendered.
INVESTIGATION FINDINGS:
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On 02/07/2024 at 09:05 AM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to deliver findings for the allegations listed above. 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.

Through the information gathered during the investigation, it was confirmed by observation, documents review and interviews that Staff are mismanaging residents medication. It was alleged that Resident #1 (R1) was not given a prescribed medication for three (3) days and Resident #5 (R5) was not given a prescribed medication for five (5) days. Per review of R1 Medication Administration Record (MAR), LPA Brown confirmed that R1 was not given the prescribed medication on 02/14/2023 to 02/16/2023. LPA Brown observed no entry on R1's MAR on 02/14/2023 to 02/16/2023. *** Continuation in LIC9099C ***
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 56-AS-20230706140934
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: 02/07/2024
NARRATIVE
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During the visit on 02/07/2024, Staff #8 (S8) unable to explain to LPA Brown why R1's MAR on 02/14/2023 to 02/16/2023 was blank, and provided LPA Brown R1's doctor order for the medication not dispensed to R1.
In addition, LPA Brown reviewed R5 MAR and observed that R5 was not given a prescribed medication on 02/24/2023 to 03/01/2023 and another prescribed medication was not given to R5 on 02/19/2023 to 02/23/2023. During the visit on 02/07/2024, S8 confirmed to LPA Brown that R5 medications on 02/24/2023 to 03/01/2023 and 02/19/2023 to 02/23/2023 was not dispensed due to required pharmacy action. LPA Brown reviewed R1 and R5's Personal Services Plan (PSP) and LPA Brown observed that ordering and coordinating medications are included on R1 and R5's PSP in addition to assistance with taking medications and medication storage. Interview with Resident #6 (R6) indicated that staffs at the facility did not give R6 medication twice and reported that staffs at the facility occasionally mismanaged their medications.

The second allegation indicates Staff are charging residents for services not rendered. LPA Brown determined that there was corroborating evidence that staff charged R1 for services not rendered. LPA Brown reviewed R1 Invoice from 02/2023 to 07/2023, and LPA Brown observed that the facility charged R1 for Escort/Mobility services not rendered or provided to R1 on 04/2023, 05/2023, and 06/2023. Staff #3 (S3) reported to LPA Brown that on incidents that a resident was charged of services not provided or rendered to the resident which happens, they immediately addressed the issue and they deduct the charged services that was not rendered or provided to the residents' account. During the visit on 02/07/2024, Staff #1 (S1) informed LPA Brown that residents are re-assess as needed and if there are any refunds needed, they give that to the residents as reflected in the residents' invoice the following month. S1 added that their facility nurses have full control of the assessment and if there are adjustments made to the residents' PSP but it's still their billing department that will adjust the amount in the residents monthly bill which takes time.

Based on observation, interview and records review, the allegation of Staff are mismanaging residents medication (Allegation #1) and Staff are charging residents for services not rendered (Allegation #2) are SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.


An exit interview was conducted and a copy of this report, LIC9099, LIC9099D 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20230706140934
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2024
Section Cited
CCR
87465(a)(6)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87465(a)(6) and submit proof of Staff Training Log to LPA Brown at Plan of Correction (POC) due date.
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Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not giving R1 and R5 their medications as prescribed by their physician which pose immediate health, safety and personal rights risks to residents in care.
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Type B
02/16/2024
Section Cited
CCR
87507(f)
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87507 Admission Agreements (f) The Licensee shall comply with all applicable terms and conditions set forth in the Admission Agreement, including all modifications and attachments. This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87507(f) 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 records review, the Licensee did not comply with the section cited above by charging R1 for Escort and mobility services not rendered or provided to R1 on 04/2023, 05/2023 and 06/2023 which pose potential health, safety and personal rights risks to residents in care.
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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
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
07/06/2023 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230706140934

FACILITY NAME:BROOKDALE NORTH EUCLIDFACILITY NUMBER:
366402583
ADMINISTRATOR:EMELIE R. FRANCOFACILITY TYPE:
740
ADDRESS:1031 N EUCLID AVETELEPHONE:
(909) 391-2622
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY:140CENSUS: DATE:
02/07/2024
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Executive Director Lisa ToTIME COMPLETED:
11:35 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are forcing residents to remove their bed rails.
Residents room floor is not level.
Staff refused to take resident's blood pressure.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/07/2024 at 09:05 AM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to deliver findings for the allegations listed above. 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.

The investigation was conducted by LPA Melody Brown. The investigation consisted of observation and interviews with relevant parties. The allegation indicates Staff are forcing residents to remove their bed rails. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Resident interviews indicated that there are no incident that happened at the facility that a staff forced a resident to remove their bed rail. Staff interviews indicated that there's no staff at the facility that's forcing residents to remove their bed rail. ***Continuation 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: 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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20230706140934
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: 02/07/2024
NARRATIVE
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Staff interviews revealed that they are recommending halo to the residents, but no incident happened that staffs are forcing residents to remove their bed rail. During the visit on 07/13/2023, R1 reported to LPA Brown that staffs at the facility are recommending halo as replacement for R1 and R5 bed rail but R1 did not state a staff forcing them to remove their bed rail.

The second allegation indicates Residents room floor is not level. Resident interviews indicated that their room floors are level, and they are not aware of a resident stating that their room floor is not level. Staff interviews indicated that no resident at the facility reported that their room floor is not level. Staff interviews revealed that none of them observed any residents' room floor not level.

The third allegation indicates Staff refused to take resident's blood pressure. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents indicated staffs at the facility are taking their blood pressure regularly and no staffs at the facility refused to take their blood pressure when they request them to check or take their blood pressure. Staff interviews indicated that they never refused to take or check a residents' blood pressure. Staffs interviews revealed that Medical Technician staffs are taking or checking residents blood pressure every month and no incident happened at the facility that a staff refused to take or check a residents' blood pressure.

Based on the evidence, the allegation that Staff are forcing residents to remove their bed rails (Allegation #1), Residents room floor is not level (Allegation #2), Staff refused to take resident's blood pressure (Allegation #3) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time.


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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 5