374601952-4-26-2023-08-AS-DNGN-CR9L7X-20230426083105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601952
Report Date: 04/25/2023
Date Signed: 04/26/2023 08:31:32 AM

Document Has Been Signed on 04/26/2023 08:31 AM - 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 OCEANSIDE		FACILITY NUMBER:	374601952
ADMINISTRATOR:	ADAMS,VALORIE		FACILITY TYPE:	740
ADDRESS:	3524 LAKE BLVD		TELEPHONE:	(760) 945-1811
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92056
CAPACITY:	186	CENSUS: 81	DATE:	04/25/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Executive Director Chris Burk		TIME COMPLETED:	05:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Chris Burk.

Today's visit was in response to an LIC624 Incident Report and an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office on 04/15/2023. According to the LIC624 and SOC341: during the early evening of 04/14/2023, Resident #1 (R1) pinched caregiver Staff #1’s (S1) arm while S1 was reaching for a TV remote. [See LIC811 Confidential Names List for a description of select person identifiers used in this report]. S1 then used their own hand to remove R1’s hand from their arm. R1 alleged that a bruise formed on their arm from this incident. Staff #2 (S2) was witness to the incident. Licensee wrote they temporarily removed S1 from caregiving duties pending internal investigation. By 04/18/2023, S1 was reinstated in their caregiving duties, but was no longer assigned to care for R1.

During today’s visit, LPA briefly toured the facility and interviewed R1, verifying that they felt safe, felt free of pain, and that no serious bodily injury was involved. By the date of LPA’s visit, there was no residual bruising present on R1’s arm. LPA also collected pertinent records and interviewed S1, other relevant staff, and multiple resident witnesses to the incident.

According to R1’s latest LIC602 Physician’s Report, R1 did not exhibit any cognitive impairment. Their doctor determined R1 was not “confused/disoriented” and denied R1 having any “aggressive behavior,” “inappropriate behavior,” or “sundowning behavior.” Their doctor wrote that R1 was “able to follow instructions” and “able to communicate needs.” During interview, LPA observed that R1 was alert, oriented, and articulate about the incident.

[CONTINUED ON LIC 809-C, 1 of 2]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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 4

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 OCEANSIDE	FACILITY NUMBER: 374601952
	VISIT DATE: 04/25/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

[CONTINUED FROM LIC 809]

Per interview of R1: they were watching a movie in a common area room with other residents. S1 came to collect and escort R1 to the dining room for dinner, but R1 insisted on finishing their movie. S1 then grabbed R1’s arm to forcefully take away a TV remote which they were holding, leaving a bruise on R1’s arm. R1 denied grabbing S1’s arm or pinching them.

Per interview of S1: S1 reached for a TV remote that was on a nearby table. R1 became upset, stood up, and grabbed S1’s left arm. S1 used their opened right hand to brush away R1’s grip on their arm. R1 then pinched S1 in their right shoulder area with their fingers. Per their seperate interview: S2 said S1 picked up a TV remote that was on a nearby table and used it to turn off the TV, upsetting R1. R1 tried to grab S1’s arm, and S1 used their open hand to brush away R1’s hand. S2 then instructed S1 to leave the area to de-escalate the situation. [LPA reviewed the written incident statements that S1 and S2 provided to licensee on 04/14/2023; S1 and S2’s verbal statements were consistent with their written statements.]

Together, R1’s, S1’s, and S2’s interviews revealed that Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4) were seated with R1 during the incident. Due to their baseline memory loss and disorientation, LPA determined the R2 was unable to participate a reliable historian/interviewee.

According to R3’s latest LIC602 Physician’s Report, they were diagnosed with Mild Cognitive Impairment. However, their doctor also determined that R3 was not “confused/disoriented,” and that they were “able to follow instructions” and “able to communicate needs.” During LPA’s interview, R3 was alert, oriented, and able to be qualified as a witness. Per interview of R3: due to the darkness in the room, they did not see if there was a physical altercation between R1 and S1, but said S1 approached the group with a rude and loud tone of voice to insist that they stop their movie. R3 said they wanted to keep watching the movie.

[CONTINUED ON LIC 809-C, 2 of 2]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

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 OCEANSIDE	FACILITY NUMBER: 374601952
	VISIT DATE: 04/25/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

[CONTINUED FROM LIC 809-C, 1 of 2]

According to R4’s latest LIC602 Physician’s Report, they were diagnosed with Mild Cognitive Impairment. However, their doctor also determined that they were “able to follow instructions” and “able to communicate needs.” During LPA’s interview, R4 was alert, oriented, and able to be qualified as a witness. Per interview of R4: they witnessed S1 grab R1’s arm to forcibly remove a TV remote from R1’s hand. R4 did not see R1 grab S1’s arm or pinch S1. R4 said they wanted to keep watching the movie.

Per interview of facility management: R1 takes blood thinner medication. A mild bruise was present on R1’s lower right arm during their investigation, but the bruise was not caused during the incident. Rather, this same bruise was already present on R1’s arm prior to the incident, as observed by S2 during their 04/07/2023 shower assistance to R1 and documented in caregiver charting. Per date and time stamped electronic progress notes: licensee notified R1’s responsible party (RP) and physician about the incident the same day it occurred, and facility management provided follow up training to their direct care staff on Resident’s Personal Rights.

Based on records and interviews, a preponderance of evidence does not exist to show that the incident between S1 and R1 constituted physical abuse or resulted in injury to R1. However, a preponderance of evidence does exists to show that S1’s did not respect resident freedom of choice, contributing to the incident occurring/escalating.

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.

An exit interview was conducted with Burk, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 04/26/2023 08:31 AM - 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 OCEANSIDE	FACILITY NUMBER: 374601952
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/25/2023 Section Cited	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility.”	1 2 3 4 5 6 7	Per interviews and record review, following the incident, facility management retrained its direct staff staff, to include S1, on Resident’s Personal Rights. Licensee agreed to E-mail LPA a copy of the training sign-in sheet, by the POC due date, as evidence. This action would resolve the deficiency.
	8 9 10 11 12 13 14	This requirement was not met, as evidenced by: Based on records and interviews, during the incident, licensee’s staff (S1) did not allow 3 of 81 residents (R1, R3, and R4) to make choices concerning their daily lives in the facility, which posed a potential personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4