374601952-6-16-2023-08-AS-DNGN-CSURKR-20230616130558

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601952
Report Date: 06/16/2023
Date Signed: 06/16/2023 01:06:06 PM

Document Has Been Signed on 06/16/2023 01:06 PM - 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: 79	DATE:	06/16/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Executive Director Chris Burk		TIME COMPLETED:	01:15 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 - Incident 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, which licensee self-submitted to the CCLD San Diego Regional Office (received on 05/20/2023), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1]. According to the LIC624: on 05/15/2023, R1 had an unwitnessed fall beside their bed, inside their bedroom. R1 denied having pain, and staff’s initial assessment did not undercover any sign of injury. The next day on 05/16/2023, R1 complained of right hip pain and had a hematoma on their forehead, so staff arranged for R1 to be transported to the hospital. As of today’s CCLD visit (06/16/2023), R1 had already moved out of the facility. However, LPA performed a brief facility tour and welfare check on remaining residents in care, seeing no immediate safety concerns. LPA also reviewed pertinent care records and interviewed relevant staff. According to R1’s LIC602 Physician’s Report (dated 04/03/2022): while R1 was diagnosed with Mild Cognitive Impairment, their doctor clarified that R1 was not “confused/disoriented.” The doctor also wrote that R1 was “able to follow instructions” and “able to communicate needs.” According to the Plan of Care which licensee authored on R1 (dated 05/04/2023), R1 was “oriented to person, place and time” and “can communicate needs and preferences.” [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: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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: 06/16/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

According to staff interviews and corroborated by the facility’s date and time stamped progress/care notes: R1 was found on the floor beside their bed during the afternoon of 05/15/2023. R1 told responding staff, med tech Staff #1 (S1) and nurse Staff #2 (S2), that they slipped out of their wheelchair while trying to transfer themselves from bed. S1 wrote that R1 denied hitting their head, denied pain, and had no visible sign of injury. R1’s vital signs, to include blood pressure and pulse, were measured and were unremarkable. Staff notified R1’s responsible person and physician of the incident, and continued to observe R1. Staff #3 (S3) documented that they checked on R1 through the night, and that R1 slept soundly without pain or discomfort. Then on 05/16/2023, Staff #4 (S4) checked on R1; R1 now exhibited right hip pain. S4 wrote that R1’s hand was also swollen/bruised, and they saw a bump on the left side of R1’s forehead. S4 arranged for R1 to be transported to the hospital and updated R1’s responsible person and physician. However, when medical transport arrived for R1, they refused to be taken to the hospital and signed a waiver for the medical transport staff. S4 continued to dialogue with R1’s responsible person. S4 arranged medical transport to come back to the facility later that same day, and this time R1 agreed to go to a local hospital.

According to staff interviews and corroborated by hospital discharge paperwork: R1 was soon released back to the facility, with their only identified injury being a “contusion” on their head. There were no bone fractures or hip or hand injuries identified. Progress/care notes and a faxed note to R1's doctor showed: after R1 discharged back to the facility, staff continued to provide increased observation to R1, and continued to communicate with R1’s responsible person and physician.

Interviews and care documents revealed that R1 wore a pendant call device/button (which is used to summon staff for help) during the slip/fall incident. LPA reviewed an electronic signals log corresponding to R1’s pendant device for 05/15/2023. The log evidenced that facility staff quickly responded to each of R1’s three (3) pendant calls, which were spread out over this date.

[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: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

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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: 06/16/2023

NARRATIVE

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

There does not exist a preponderance of evidence showing that licensee’s staff did not provide needed care or observation to R1, or that licensee did not arrange for needed emergency medical care for R1 when it became warranted. No deficiency was cited for the above incident.

Also, no deficiency was observed or cited during today’s licensing visit. However, LPA identified one Technical Violation regarding Reporting Requirements, and provided education, accordingly.

An exit interview was conducted with Burk, to whom a copy of this report, the LIC9102-TV, 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: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

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