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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600735
Report Date: 03/07/2023
Date Signed: 04/04/2023 09:41:38 AM


Document Has Been Signed on 04/04/2023 09:41 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



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: 79DATE:
03/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director, Candi LairdTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced Case Management visit to discuss a deficiency discovered during a complaint investigation. The LPA identified himself and discussed the purpose of the visit with Executive Director, Candi Laird.

Interviews revealed Resident # 1 (R1) was involved in an incident that threatened R1’s welfare, safety, and health. The facility did not submit a written report to the Department within seven days of the incident, as defined in California Code of Regulations, Title 22. This deficiency was cited in an LIC 809D, and a Plan of Correction was jointly formulated with the facility administrator.

An exit interview was conducted with Executive Director, Candi Laird, to whom a copy of this report, LIC 809D, LIC 811 and Licensee/Appeals Rights (LIC 9058) were provided.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
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 04/04/2023 09:41 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BROOKDALE CLAIREMONT
FACILITY NUMBER: 374600735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2023
Section Cited

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87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by:
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Administrator agreed to provide reporting requirement training for staff, from an outside vendor. Administrator agreed to submit proof of completed trainings, and participants, by 4/7/2023.
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Based on interviews, the licensee did not ensure the facility submitted a written report to the Department, which posed a potential health, safety, and personal rights risk to 1 of 79 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: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
LIC809 (FAS) - (06/04)
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