374601046-11-3-2020-08-AS-RHEK-BVV7H2-20201130204000

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374601046
Report Date: 09/09/2020
Date Signed: 11/03/2020 02:43:29 PM

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
09/24/2019 and conducted by Evaluator Anna Kennedy

COMPLAINT CONTROL NUMBER: 08-AS-20190924125949

FACILITY NAME:	BROOKDALE PLACE OF SAN MARCOS		FACILITY NUMBER:	374601046
ADMINISTRATOR:	HEILGEIST, MARY ELLEN		FACILITY TYPE:	740
ADDRESS:	1590 W SAN MARCOS BLVD		TELEPHONE:	(760) 471-9904
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92078
CAPACITY:	245	CENSUS:	DATE:	09/09/2020
		UNANNOUNCED	TIME BEGAN:	01:28 PM
MET WITH:	Mary Ellen Heilgeist		TIME COMPLETED:	02:29 PM

ALLEGATION(S):

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Facility staff failed to afford resident privacy.
Facility staff did not use universal precautions.
Facility staff failed to safeguard resident's personal belongings.
Facility staff failed to clean resident's room properly.
Facility staff did not treat resident with dignity and respect.
Facility staff failed to keep accurate information regarding a resident's mental condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kennedy conducted a complaint visit via a video-calling app due to COVID-19 restrictions to deliver the findings for the above allegations. LPA identified herself and stated the purpose of the video-call to Mary Ellen Heilgeist, Executive Director.

During the course of the investigation, LPA toured the facility, reviewed records and conducted in-person and telephonic interviews.

It was alleged that the facility staff failed to afford a resident privacy, specifically regarding an isolated incident where it was alleged that a man came into a Resident1’s (R1) (see LIC 811 for a list of confidential names) apartment without knocking or identifying himself. The specific date could not be ascertained by the available data.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna Kennedy	TELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

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-20190924125949

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 PLACE OF SAN MARCOS	FACILITY NUMBER: 374601046
	VISIT DATE: 09/09/2020

NARRATIVE

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The LPA spoke with multiple facility staff members and was informed that it is the policy for all employees who need to enter a resident’s apartment to knock and announce themselves. If there is no response, the staff member can let themselves into the room, announcing themselves again. If an outside entity needs to provide maintenance, they would be accompanied by a member of the maintenance staff. The individual and date of the allegation could not be provided, and the available data does not meet the standard for substantiation, therefore this allegation is Unsubstantiated.

It was further alleged that facility staff failed to use universal precautions when a staff member took a bag believed to contain items discarded after R1’s roommate had received incontinence care, being dragging across the kitchen counter to place in the kitchen trash. The date and staff member could not be identified. LPA spoke with members of the facility staff responsible for training and supervising care staff and with direct care staff members and learned that staff are trained to dispose of all waste from provision of incontinence care, and any other personal care, in a tied plastic bag and either dispose of the bag in the bathroom, or remove it from the apartment. To the best of their recollection a concern such as the one outlined in this allegation has not been raised. With the limited data available regarding this allegation, it could not be substantiated, therefore this allegation is Unsubstantiated.

It was alleged that R1’s property was not properly safeguarded because they had items disappears from their apartment and R1 alleged that their email and other electronic items were hacked or compromised by facility staff.

R1 expressed a belief that their electronic items had been used and altered by facility staff. No evidence supporting this allegation could be located or provided during the course of the investigation.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna Kennedy	TELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20190924125949

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 PLACE OF SAN MARCOS	FACILITY NUMBER: 374601046
	VISIT DATE: 09/09/2020

NARRATIVE

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R1 did report to facility management that a cat carrier of unknown value was missing. The cat carrier had been outside the apartment on R1’s patio prior to its disappearance. The loss was logged on the facility theft and loss record and also noted that the item was never located. R1 mentioned other missing items that had a value significantly under the $25 required to fall under the facility theft and loss policy. R1 was provided with and signed a copy of the facility theft and loss policy upon admission. The theft and loss policy was followed. Additionally, this item was not in the care of the facility for safeguarding. The available evidence does not support this allegation; therefore this allegation is Unsubstantiated.

R1 reported that historically, when R1 had a roommate with exceptional needs, the facility staff were in and out of the room a lot and it was not cleaned to R1's standards. LPA spoke with facility staff including those with responsibility for housekeeping and was informed that anytime a resident expresses a concern that their apartment was not cleaned adequately, a housekeeper was sent to the apartment to provide any needed additional cleaning. LPA was informed that the facility provides specific cleaning tasks and that some residents expect cleaning services beyond what is identified in the admission agreement. With the lack of specificity regarding this allegation, the standard for substantiation could not be met, therefore this allegation is Unsubstantiated.

R1 alleged that on “a couple of occasions” facility staff would enter their apartment to provide care to the roommate and did not acknowledge R1. R1 stated that facility staff would take food off R1’s plate and put it on R1’s roommate’s plate showing a “general disregard” for R1. R1’s report is historical and the number of occasions and precise dates could not be identified. LPA spoke with the multiple members of the facility staff and learned facility staff are trained to greet all residents by name and inquire as to their well-being. They should greet residents in such a manor if they encounter them in their apartments, or in the public area of the community. LPA was also informed that a care provider may not be as attentive to a resident that in not receiving care, as one who is. As this allegation is vague in terms of concern and time of occurrence, the standard for substantiation could not be met, therefore this allegation is Unsubstantiated.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna Kennedy	TELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20190924125949

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 PLACE OF SAN MARCOS	FACILITY NUMBER: 374601046
	VISIT DATE: 09/09/2020

NARRATIVE

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It was lastly alleged that facility staff failed to keep accurate information regarding a resident's mental condition. This allegation is based on a physician’s report provided to the facility by R1’s physician that stated that R1 had Mild Cognitive Impairment (MCI). When R1 became aware of the MCI diagnosis on the physician’s report, R1 raised the concern with their physician who issued a correction to the physician report stating that R1 does not have MCI. The allegation is that the facility staff provided the physician false information about R1 that resulted in the original physician’s report with the MCI diagnosis.

The investigation revealed that the facility did provide information to the physician as part of the medical reassessment process. Among the documents provided was a form completed by a different physician at the time of R1’s admission to the facility that states that R1 “has Mild Cognitive Impairment and is still mentally able/safe to leave the facility unassisted.” In retracting the diagnosis of MCI, the physician wrote that they “incorrectly indicated (R1) has mild cognitive impairment on (the physician’s report).
Mini-Mental State Examination (MMSE) was 29/30 today and (R1) does not have mild cognitive impairment.” The physician is responsible for the initial diagnosis, and the retraction. The evidence does not support the allegation that the facility provided false information to the physician. This allegation is Unsubstantiated.

An exit interview was conducted with Mary Ellen Heilgeist, Executive Director. via video-call. A copy of this report along with Licensee Rights (LIC9058 01/2016) was provided to Ms. Heilgeist via email. An electronic response confirms the documents were received.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna Kennedy	TELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

LIC9099 (FAS) - (06/04)

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