374600735-9-23-2021-08-AS-IESA-C8A4X8-20211029192904

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600735
Report Date: 09/22/2021
Date Signed: 09/23/2021 03:57:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/16/2019 and conducted by Evaluator Laarni Santiago

COMPLAINT CONTROL NUMBER: 08-AS-20191016085626

FACILITY NAME:	BROOKDALE CLAIREMONT		FACILITY NUMBER:	374600735
ADMINISTRATOR:	WHEELER, SARAH		FACILITY TYPE:	740
ADDRESS:	5219 CLAIREMONT MESA BLVD		TELEPHONE:	(858) 292-8044
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92117
CAPACITY:	214	CENSUS: 90	DATE:	09/22/2021
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Foudhil Manadi, Executive Director		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Questionable Death
Failed to administer medications as prescribed
Facility failed to provide physician prescribed device
Facility failed to provide incontinence care
Facility failed to meet resident's needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Laarni Santiago conducted an unannounced visit to conclude the investigation and deliver findings. LPA stated the purpose of the visit and spoke with Foudhil Manadi, Executive Director.

The findings rendered are based on an investigation conducted by the Department. The investigation included a review of facility and medical records, as well as interviews conducted with staff and outside sources.

It was alleged that the facility neglected to provide pain medication for Resident #1 (R1) which contributed to death. Investigation revealed that on July 19th, 2019, R1 sent out to the hospital due to their inability to stand up and presented symptoms of cough, nausea, vomiting, back pain and confusion. Interviews and records revealed that prior to R1’s admission to the hospital on July 19th, 2019, R1 was ambulatory, independent with transferring and able to communicate needs. Although R1 was a fall risk, R1 used

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni Santiago	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021

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 08-AS-20191016085626

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BROOKDALE CLAIREMONT	FACILITY NUMBER: 374600735
	VISIT DATE: 09/22/2021

NARRATIVE

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assistive device for mobility aid and had a call alert system to request for assistance. A review of their care plan indicate that facility implemented fall precautions for R1. On the evening of August 2nd, 2019, R1 was discharged back to the facility and transitioned to Hospice care due to their medical condition. On August 3rd, 2019, medical records suggest that R1 was prescribed morphine and was given by an outside source due to complaints of back pain. On August 5th, 2019, around 10:oo PM, Staff 1 (S1) ) Hospice to request for morphine tabs and to notify that R1 had increased agitation. Facility staff was advised that a nurse would be out soon to assess R1. Around midnight, S1 checked on R1 and observed to be sleeping. Around 1:00AM, R1 was heard talking and moaning; S1 conducted a welfare check and R1 stated they were feeling agitated and worried, therefore, PRN medications were administered. Around 3:00AM, S1 found R1 on the floor. Facility initiated 9-1-1 and contacted hospice. Subsequently, it was determined that R1 had expired in-spite of EMS attempt to resuscitate. Death certificate revealed that R1’s cause of death was Heart Failure and Essential Primary Hypertension. Based on interviews conducted and records reviewed, the allegation is deemed to be unsubstantiated.

It was alleged that on August 3rd, 2019, the facility staff failed to provide medication for R1 when it was requested to alleviate pain. When R1 transitioned into hospice care on August 2nd, 2019, they were prescribed a PRN, sublingual morphine oral solution. During that time, R1 was unable to administer their own medication due to the status of their health condition. Staff interviews revealed that they were not qualified staff to administer morphine since they are not licensed professionals. Further evidence obtained from facility’s personnel records corroborates that their credentials did not qualify them as an appropriately licensed professional. Record reviews indicate that on August 3rd, 2019, R1 was provided morphine by a hospice nurse. Hospice notes revealed that staff consistently notified hospice agency when R1 needed morphine and had been able to provide alternative pain medication when morphine could not be immediately dispensed. Multiple attempts were made by the Department to contact S1 to attest to the incident but were unsuccessful. Based on information gathered from interviews and record reviews, the allegation is deemed to be unsubstantiated.

It was alleged that R1 was prescribed a hospital bed with rails to assist with mobility but was not supplied by the facility. A review of hospice records indicates that a hospital bed with extender was ordered on August 3rd, 2019. Hospice records revealed that R1’s family member requested for a hospital bed without a bed rail on August 4th, 2019. Interview conducted with Administrator indicated that the facility was waiting for Hospice to assess R1 prior to delivering hospital bed. Evidence obtained from hospice records indicate that the

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni Santiago	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20191016085626

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BROOKDALE CLAIREMONT	FACILITY NUMBER: 374600735
	VISIT DATE: 09/22/2021

NARRATIVE

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hospital bed was initially ordered on August 3rd, 2019. A review of facility notes suggests that on August 4th, 2019, the facility followed-up with hospice regarding the order for hospital bed. The following day, R1 had expired and there was no corroborating evidence to suggest whether R1’s hospital bed was delivered or not. The Department was also unable to interview S1 regarding this allegation. Based on the interviews conducted and records reviewed, the allegation is deemed unsubstantiated.

It was alleged that the facility staff failed to provide incontinence care to R1 when an outside source requested staff to change them. A review of R1’s current medical assessment dated July 18th, 2019, indicated that they were ambulatory, able to care for own toileting needs, and did not have any bladder issues. Evidence obtained from current needs and services plan also indicated that R1 did not require any toileting assistance. On August 2nd, 2019, R1 was discharged back to the facility from hospital and transitioned into hospice care. Hospice records reviews indicated that upon discharge from hospital, R1 transitioned from an independent status to being dependent with all aspects of Activities of Daily Living (ADL) which included assistance with toileting. However, interviews with outside sources, staff, and records review does not corroborate how facility failed to provide incontinence care for R1. The Department was also unable to interview relevant individuals with firsthand knowledge of the allegation as they failed to return numerous attempted phone calls from the Department. Based on interviews and records reviewed, the allegation is deemed unsubstantiated.

It was alleged that the facility failed to meet R1’s nutritional and hygiene needs. A review of current medical assessment dated July 18th, 2019, suggest that R1 was independent in all aspect of ADLs which included being able to feed themselves. Needs and Services Plan revealed that R1 was eating regular meal portions with no dietary restrictions. An interview with outside sources and records revealed that approximately a month before hospitalization and transition into hospice care, R1 was able to consume 3 meals per day. Based on hospice records, R1’s food intake went from 100% to 10% which implies that they no longer had an appetite. However, based on interviews and records review, there were no corroborating evidence to suggest that R1 was not provided a proper nutrition while at the facility. In addition, hospice records and interviews with outside sources revealed that R1 had a Certified Home Health Aide (CHHA) to assist with bathing. Prior to discharge from the hospital on August 2nd, 2019, R1 was independent with bathing and showering, and was receiving minimal assistance from staff. The Department was also unable to interview relevant individuals with firsthand knowledge of the allegation as they failed to return numerous attempted phone calls from the Department. Based on interviews and records reviewed, the allegation is deemed unsubstantiated.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni Santiago	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 08-AS-20191016085626

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BROOKDALE CLAIREMONT	FACILITY NUMBER: 374600735
	VISIT DATE: 09/22/2021

NARRATIVE

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The Department has investigated the above allegations. Based on evidence obtained, including interviews and records reviewed, the allegations are determined as Unsubstantiated because the preponderance of the evidence standard has not been met.

An exit interview was conducted with Executive Director (ED) and a copy of this report and Licensee/Appeals Rights (LIC 9058 01/16) was provided to ED via email. An electronic receipt of confirmation was requested to be sent by the Licensee upon receipt of the documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni Santiago	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021

LIC9099 (FAS) - (06/04)

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