<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600735
Report Date: 03/07/2023
Date Signed: 04/13/2023 01:25:34 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
02/07/2023 and conducted by Evaluator Sabel Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230207152951
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
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director, Candi LairdTIME COMPLETED:
03:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not seek medical care for a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This is an amended report to a report originally signed on 3/7/23.

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director, Candi Laird.

Throughout the investigation, the Department secured pertinent records and conducted interviews with internal and external sources, including residents, staff, and outside sources.
It was alleged Facility staff did not seek medical care for a resident. Interviews with internal and external sources revealed staff witnessed Resident # 1 (R1) was witnessed having a medical health emergency that posed an imminent threat to R1’s health and safety. A review of the facility’s plan of operations and house rules revealed it was the facility’s policy to call 911 in case of an emergency.
(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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 08-AS-20230207152951
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: 03/07/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interviews with internal and external sources corroborated the facility staff did not call 911 upon witnessing during R1’s health emergency, as required.

Based on evidence obtained, the preponderance of evidence standard was met, therefore, the allegation was Substantiated. The deficiency was cited and listed on an LIC 9099D. 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 811, LIC 9099D 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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20230207152951
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: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2023
Section Cited
CCR
87465(g)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (g)The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to provide in service training for all staff regarding when to call 911. Administrator will submit proof of completed traininigs, and participants, by 4/7/2023.
8
9
10
11
12
13
14
Based on interviews, the licensee did not ensure facility staff telephone 911 after an incident that resulted in an imminent threat to the health of R1, which posed a potential health, safety, and personal rights risk to 1 of 79 residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
02/07/2023 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20230207152951

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
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director, Candi LairdTIME COMPLETED:
03:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not notify resident's responsible party of an unusual incident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director, Candi Laird.

Throughout the investigation, the Department secured pertinent records and conducted interviews with internal and external sources. It was alleged Facility staff did not notify resident's responsible party of an unusual incident. Interviews with internal sources revealed staff reported the incident to the responsible party within the timeframe stated in the California Code of regulations, Title 22. This was corroborated through review of documents obtained at the facility. Based on the evidence gathered throughout the investigation, there was not a preponderance of evidence to prove the alleged violation occurred, therefore, the allegation was Unsubstantiated.

An exit interview was conducted with Executive Director, Candi Laird, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058) were provided.
Unsubstantiated
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: 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.
LIC9099 (FAS) - (06/04)
Page: 4 of 4