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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601046
Report Date: 06/23/2023
Date Signed: 06/23/2023 01:27:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
06/20/2023 and conducted by Evaluator Chinwe Nwogene
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230620170148
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: 150DATE:
06/23/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Mario Preston, Executive Director TIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Unlawful eviction.
INVESTIGATION FINDINGS:
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On 06/23/2023, Licensing Program Analyst (LPA) Chinwe Nwogene conducted an unannounced visit to investigate the above allegation. LPA met with Executive Director, Mario Preston who was informed of the purpose of the visit. At the time of visit, LPA interviewed staff and reviewed resident’s records.
Regarding the allegation “Unlawful eviction”, it was alleged the facility served resident a 30days eviction notice because facility can no longer accommodate resident. LPA interviewed Executive Director who acknowledged a 30day eviction notice was issued to resident on 2/7/2023 for reason of “delusional behavior and hallucination”. Executive Director stated resident requires a higher level of care than the facility can provide. LPA inquired if a Psych evaluation or assessment was conducted, Executive Director stated no that the resident refused. LPA reviewed residents file and observed no documentation of resident being diagnosed with delusion and hallucination.
Based on LPA’s observation, interview and file review, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division & Chapter number) are being cited on the attached LIC 9099D). An exit interview was conducted, and a copy of this report was reviewed with and provided to Mario Preston.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
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 2
Control Number 18-AS-20230620170148
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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: 06/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
07/03/2023
Section Cited
CCR
87224(a)(4)
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Eviction Procedures;
The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5).
If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident.
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Administrator stated facility will have resident assessed and properly diagnosed.
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This requirement is not met based as evidence by observation, interview, and record review. The licensee did not comply by evicting resident without proper diagnosis which poses a potential health, safety or personal rights 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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC9099 (FAS) - (06/04)
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