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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600735
Report Date: 08/11/2022
Date Signed: 08/11/2022 06:29:11 PM


Document Has Been Signed on 08/11/2022 06:29 PM - 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: 93DATE:
08/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH: Business Office Manager, Nicole NobleTIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Sabel Martinez, conducted a case management visit to cite a deficiency observed during a complaint investigation visit. The LPA was greeted by Business Office Manager, Nicole Noble, identified himself and disclosed the purpose of the visit.

During today's visit, while conducting interviews with residents, the LPA observed prescribed medication to be readily accessible to Resident #1(R1). A review of R1's LIC 602, Physician's Report, revealed R1 is not able to administer own medication, and is not able to store own medication. Per California Code of Regulations, Title 22. this deficiency was cited in an LIC 809D.

An exit interview was conducted with Business Office Manager, Nicole Noble, to whom a copy of this report, LIC 809D, LIC 811 Confidential names list and Licensee's Rights (LIC 9058 01/16) were provided to.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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 08/11/2022 06:29 PM - 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: 08/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2022
Section Cited

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87465 Incidental Medical and Dental (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances:(B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement was not met as evidenced by:
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Based on observation, interview, and record review the licensee did not ensure R1's medication was centrally stored which posed an immediate Health, Safety, and Personal Rights risk to 1 of 93 persons in care
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Business Office Manager agreed to conduct staff training regarding centrally stored medication and provide proof of the training by 9/11/22.

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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: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
LIC809 (FAS) - (06/04)
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