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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600735
Report Date: 09/22/2023
Date Signed: 09/22/2023 05:17:27 PM


Document Has Been Signed on 09/22/2023 05:17 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: 78DATE:
09/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Executive Director Candi LairdTIME COMPLETED:
05:30 PM
NARRATIVE
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LPA Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Candi Laird.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 09/08/2023). According to the LIC624: during the evening of 09/02/2023, an error by Staff #1 (S1) led to Resident #1 (R1) receiving doses of multiple medications which were not prescribed to them. These medications were instead prescribed to Resident #2 (R2). [See LIC 811 Confidential Names List for a description of select person identifiers used in this report].

During today’s visit, LPA performed a facility tour and welfare check, finding that R1 was alert, animated, and unharmed. LPA also reviewed pertinent care records and interviewed R1 and relevant staff. Due to their baseline memory loss, R1 vaguely remembered the incident, but could not provide meaningful details about it.

According to R1’s latest LIC602 Physician’s Report (dated 11/10/2022): R1 was diagnosed with Mild Cognitive Impairment and their physician determined that they required staff assistance with storing and taking their prescribed medications. Facility manager interview corroborated this need.

Facility staff interviews, corroborated by date and time stamped progress notes and other records, showed: During the PM shift on 09/02/2023, S1 placed the medications for R1 and R2 into two separate cups. However, S1 handed R2’s cup to R1 by mistake. By the time S1 recognized the mistake, R1 had ingested multiple of R2’s medicines. However, S1 caught their error timely enough that R2 did not ingest any of R1’s medicines. The medication errors which affected R1 during the evening of 09/02/2023 did not prevent R2 from receiving their respective prescribed medications on that date. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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
VISIT DATE: 09/22/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

Licensee's staff timely notified R1’s primary care physician (PCP) and R1’s responsible person. They continued to observe R1 and measure their vital signs over the next several hours. R1 did not develop any adverse heath symptoms. After the incident, Licensee arranged for the facility’s medication technicians to be retrained on accurate medication pass procedures; S1 was among the trainees.

A preponderance of evidence exists to show: During the incident in question, License’s staff (S1) did not give R1 medications as they were prescribed. The incident did not result in injury or serious illness to R1. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding reporting requirements.

An exit interview was conducted with Laird, to whom a copy of this report, the LIC 809-D, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/22/2023 05:17 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: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2023
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:
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Per manager interview and training records: On 09/08/2023, Licensee conducted a retraining of relevant staff on accurate medication pass procedures; the trainees included S1. This action resolves the deficiency.
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Based on records and interviews, the licensee did not assist 1 of 78 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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