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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601560
Report Date: 10/26/2023
Date Signed: 10/26/2023 02:35:18 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
10/18/2023 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20231018143535
FACILITY NAME:GLENBROOK ASSISTED LIVINGFACILITY NUMBER:
374601560
ADMINISTRATOR:HARNESS, SADIEFACILITY TYPE:
740
ADDRESS:1950 CALLE BARCELONATELEPHONE:
(760) 704-6800
CITY:CARLSBADSTATE: CAZIP CODE:
92009
CAPACITY:95CENSUS: 68DATE:
10/26/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Sadie HarnessTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Neglect/Lack of Supervision resulted in resident injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to initiate a complaint investigation in the above-mentioned allegation. LPA met with Administrator Sadie Harness and discussed the purpose of the visit.

On October 18, 2023, Community Care Licensing (CCL) received a complaint alleging neglect/lack of supervision resulted in Resident 1 (R1) injury. During the investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews.

According to R1’s Physician Report dated May 23, 2023, R1 is diagnosed with a major neurocognitive disorder, is confused, and disoriented and has sundowning behaviors. Records collected also show R1 has occasional hallucinations and delusions. R1 care plan dated May 4, 2023, does not reveal any additional status checks necessary for R1. According to the allegation, on October 18, 2023, R1 was observed to have a large bruise on the left arm. Interviews with multiple staff did not reveal what the direct source of the bruise was.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
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 08-AS-20231018143535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GLENBROOK ASSISTED LIVING
FACILITY NUMBER: 374601560
VISIT DATE: 10/26/2023
NARRATIVE
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Outside source interview revealed that medical provider could not verify that this injury was caused by another person. Interviews with residents did not reveal any information to corroborate the allegation.

Based on LPA's interviews, and record reviews there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Administrator Sadie Harness, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2