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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600735
Report Date: 02/09/2023
Date Signed: 02/09/2023 05:38:07 PM

Substantiated


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
11/09/2022 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20221109165021
FACILITY NAME:BROOKDALE CLAIREMONTFACILITY NUMBER:
374600735
ADMINISTRATOR:PIERFAX, JUDITHFACILITY TYPE:
740
ADDRESS:5219 CLAIREMONT MESA BLVDTELEPHONE:
(858) 292-8044
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:214CENSUS: 80DATE:
02/09/2023
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Executive Director, Candi LairdTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Facility has pests
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. The LPA introduced himself and disclosed the purpose of the visit to Executive Director, Candi Laird.

The Department’s investigation consisted of observations, review of records, and interviews with internal and external sources.

It was alleged the facility had pests. Review of the Field Automation System (FAS) revealed the facility was cited in September of 2022 for not providing health and comfortable accommodations, resulting from the facility having pests.

(See LIC 9099C for continuation of report.)
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
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 3
Control Number 08-AS-20221109165021
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: 02/09/2023
NARRATIVE
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From October 2022 to February 2023, interviews with internal sources, external sources and review of records obtained from the facility, revealed cockroaches were witnessed inside the facility. Lack of room preparation, clutter and stored items in the residents' rooms had limited the access for services from a professional pest control company, and limited treatment. This resulted in treatment not being provided according to protocol.

Based on the evidence gathered, the preponderance of evidence standard was met, therefore, the allegation was substantiated. Per California Code of Regulations , Title 22, the deficiency was cited in an LIC 9099D, and civil penalty was assessed in and LIC 421 FC for a repeat violation within twelve months. A Plan of Correction was jointly formulated with Executive Director, Candi Laird.

An exit interview was conducted with Executive Director, Candi Laird, to whom a copy of this report, LIC 9099D, LIC 421FC, and Appeal Rights (LIC 9058) were provided to.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20221109165021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by:
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Administrator agreed to provide room preparation training, from an outside vendor or professional pest company, to maintenance staff and housekeeping staff. Administrator will provide documentation of scheduled training date, staff who will attend, and date of completion, by 3/9/2023.
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Based on interviews, and records reviewed, the licensee did not ensure the residents had healthful accommodations and did not treat a cockroach infestation effectively, which posed a potential health, safety, and personal rights risk to 80 of 80 persons 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: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3