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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601046
Report Date: 04/25/2022
Date Signed: 04/25/2022 02:47:03 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220420140729
FACILITY NAME:BROOKDALE PLACE OF SAN MARCOSFACILITY NUMBER:
374601046
ADMINISTRATOR:PRESTON, MARIOFACILITY TYPE:
740
ADDRESS:1590 W SAN MARCOS BLVDTELEPHONE:
(760) 471-9904
CITY:SAN MARCOSSTATE: CAZIP CODE:
92078
CAPACITY:245CENSUS: 163DATE:
04/25/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Mario Preston - AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff failed to meet resident's needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Mario Preston. Below is a summary of the complaint investigation findings:

Regarding allegation "Staff failed to meet resident's needs": LPA Colvin conducted interviews with resident(s), staff, and other related parties as well as reviewed records for the resident (R1) in relation to this complaint. LPA Colvin learned that while R1 is labeled as "Independent" by the facility, it is clearly documented through R1's file that R1 has severe hearing impairment, though this is somewhat managed through hearing aid devices. In LPA Colvin's interviews, it was relayed that three separate persons informed facility staff of R1's hearing aid(s) being broken and R1 having difficulty being able to communicate with others. According to interviews, despite staff stating that they would help facilitate communicate with R1 and persons attempting to call R1, staff reportedly failed to do so, and R1's callers were never further assisted in communicating with R1.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
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 18-AS-20220420140729
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BROOKDALE PLACE OF SAN MARCOS
FACILITY NUMBER: 374601046
VISIT DATE: 04/25/2022
NARRATIVE
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Additionally, according to interview(s), prior to R1's callers informing facility staff of R1's broken hearing aid(s) on 4/20/22, R1 had reached out to facility staff to inform them of the issue. This included both speaking with "Manager on Duty" and leaving multiple notes for the Administrator on days that the Administrator was not present. In interviews with Administrator Mario Preston, it was denied that they had ever received a note from R1 requesting to meet with them. LPA Colvin confirmed with facility staff that notes have been left by R1 for Administrator Mario, though staff are not aware of the contents of said notes.

Administrator Mario Preston additionally denied any knowledge of R1's hearing aid(s) being broken prior to 4/20/22. Progress Notes for R1 do show that on 4/20/22, facility staff check on R1 and were able to communicate with R1 via white board. There is no evidence to suggest that staff additionally assisted resident's callers with communicating with R1, or that staff notified R1 of persons attempting to get in contact with R1. Staff deny requests from anyone to assist with speaking with R1.

Therefore, due to facility staff's failure to assist R1 in communicating with callers (when the need was presented to them) as well as facility staff failing to assist R1 with obtaining a new hearing aid or notifying their Power of Attorney (POA) of the need for a new hearing aid when R1 presented concerns, the allegation "Staff failed to meet resident's needs" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited, and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Administrator Mario Preston during the exit interview.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20220420140729
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROOKDALE PLACE OF SAN MARCOS
FACILITY NUMBER: 374601046
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2022
Section Cited
CCR
87466
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Observation of the Resident: The...residents are regularly observed for changes...and that appropriate assistance is provided when such observation reveals unmet needs...such changes are documented and brought to the attention of ...the resident's responsible person, if any. This requirement was not met by
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Licensee agrees to have staff re-trained on Personal Rights of Residents as well as have staff trained on communication with those hard of hearing, including signs of impairment. Licensee to provide LPA Colvin with plan for training including dates and instruction matieral by Plan of Correction date of 4/26/22.
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Based on interviews, the Licensee did not comply with the above regulation with one resident. Staff failed to assist friends/family with communicating with R1 when they were informed of R1's impairment. Additionally, R1's requests for help were unanswered. This was an immediate personal rights violation of R1.
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Licensee to further submit records of completed training to LPA Colvin once all staff have participated in training.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220420140729

FACILITY NAME:BROOKDALE PLACE OF SAN MARCOSFACILITY NUMBER:
374601046
ADMINISTRATOR:PRESTON, MARIOFACILITY TYPE:
740
ADDRESS:1590 W SAN MARCOS BLVDTELEPHONE:
(760) 471-9904
CITY:SAN MARCOSSTATE: CAZIP CODE:
92078
CAPACITY:245CENSUS: 163DATE:
04/25/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Mario Preston - AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff refused to provide transportation for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unanounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Mario Preston. Below is a summary of the complaint investigation findings:

Regarding allegation "Staff refused to provide transportation for resident": LPA Colvin conducted interviews with staff, resident(s), and other persons with knowledge related to the allegation. While interviews conducted conflict on whether or not the facility initially refused transportation for R1 to an appointment, or if R1 was going to be charged for the transportation, LPA Colvin was able to confirm that the facility did in fact provide transportation to R1 to their appointment on 4/23/22. Therefore, the allegation of "Staff refused to provide transportation for resident" is UNFOUNDED. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Mario Preston and report provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
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