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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603617
Report Date: 09/24/2021
Date Signed: 09/24/2021 06:19:58 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/09/2019 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20190909092657
FACILITY NAME:BROOKDALE CARMEL VALLEYFACILITY NUMBER:
374603617
ADMINISTRATOR:MCDONALD, JASONFACILITY TYPE:
741
ADDRESS:13101 HARTFIELD AVETELEPHONE:
(858) 259-2222
CITY:SAN DIEGOSTATE: CAZIP CODE:
92130
CAPACITY:125CENSUS: 69DATE:
09/24/2021
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Executive Director Erika CastileTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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-Licensee did not assist resident with medication as required.
-Licensee did not meet reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Complaint Visit to deliver findings regarding the above allegations. LPA was greeted by and identified himself to receptionist Jaime Gomez. LPA then met and discussed the purpose of the visit with Executive Director Erika Castile.

Resident #1 (R1) [see LIC811 Confidential Names list to identify R1] fell on 12-09-2018. It was alleged that during the overnight "NOC" shift on 12-13-2018, licensee did not assist R1 with as needed pain medication (for which there existed an active and valid doctor’s prescription) after R1 requested it. It was also alleged that licensee did not provide R1’s responsible party (RP) a copy of the LIC624 Unusual Incident/Injury Report (“the written report”) about the 12-09-2018 fall, within the legally required timeframe. The Department’s investigation consisted of reviewing pertinent hospital records, facility care records, and electronic correspondence between RP and licensee. Relevant facility staff, residents, and outside sources were also interviewed. [CONTINUED ON LIC 9099-C, 1 of 2]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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 08-AS-20190909092657
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 CARMEL VALLEY
FACILITY NUMBER: 374603617
VISIT DATE: 09/24/2021
NARRATIVE
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[CONTINUED FROM LIC 9099]

It was revealed R1 indeed fell on 12-09-2018 after coming into contact with another resident’s motorized scooter. R1 initially suffered skin abrasions and pain in left shoulder and right hip that required R1 to be sent to a hospital emergency room (ER). While at the ER, R1 received a full 5-325 mg tablet of HYDROcodone-acetaminophen (aka “NORCO”) for pain. R1 discharged from the ER and returned to the facility later that same night. Hospital discharge paperwork indicated R1 had a new medication order: up to half a 5-325 mg tablet of NORCO every four hours, as needed (PRN) for breakthrough pain, effective 12-09-2018 and to be discontinued after 10 doses are expended. It was subsequently discovered during a 12-16-2018 ER visit that R1 had sustained new compression fractures to the spine.

The Department interviewed five (5) Medication Technicians and four (4) Nurses who were active with R1 in the week following their fall, plus the 2 Caregivers assigned to the 12-13-2018 NOC shift, which runs from approximately 10:00 PM to 6:00 AM. Six (6) of these eleven (11) staff recalled hearing of a complaint/incident occurring on that NOC shift, where R1 requested PRN pain medication but a staff member refused to give it. Due to fading memories, some staff could not remember the specifics. However, Staff #1 (S1) and Staff #2 (S2), who were in supervisory roles and investigated the matter, said R1 told Staff #3 (S3) [see LIC811 Confidential Names list to identify S3] that they were in pain and “wanted to see the nurse,” instead of specifically asking for pain medication. S1 and S2 provided corrective coaching to S3 about recognizing pain and critical thinking. S1 and S2 said an informal coaching document memorialized the conversation, but neither could produce a copy of it upon LPA’s request. When S3 was interviewed, they vaguely remembered an incident where a resident requested pain medication and did not receive it. However, they could not recall which staff or resident was involved. Meanwhile, interview of R1 and an outside source revealed that R1 specifically asked for pain medication on the night of 12-13-2018.

[CONTINUED ON LIC 9099-C, 2 of 2]
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20190909092657
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 CARMEL VALLEY
FACILITY NUMBER: 374603617
VISIT DATE: 09/24/2021
NARRATIVE
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[CONTINUED FROM LIC 9099, 1 of 2] Interviews of eleven (11) of eleven (11) facility staff affirmed R1 was unimpaired in both speech and cognition and able to ask for what they wanted. R1’s LIC602 Physician’s Report corroborated that R1 had no confusion/disorientation and was “able to follow instructions” and “able to communicate needs.” Moreover, the facility’s Point Click Care (PCC) Electronic Medication Administration Record (“EMAR”) software revealed R1 received NORCO at 5:32 PM on 12-13-2018, and then on 12-14-2018 at 7:37 AM, 4:16 PM, and 10:02 PM, and on 12-15-2018 at 1:42 AM, 8:37 AM, and 10:32 PM. However, noticeably absent was a record of NORCO being given during the NOC shift on 12-13-2018.

With regard to the allegation that licensee did not meet reporting requirements, it was revealed that licensee timely phoned RP about the 12-09-2018 incident, on the day it occurred. However, RP made repeated verbal and written requests to licensee for a copy of the written report, but did not receive it within seven days of the incident. LPA obtained a 12-14-2018 timestamped E-mail in which RP made an explicit request to licensee for the written report, stated that prior verbal and written requests were made, and that they felt “ignored” and “stonewalled.” LPA also obtained: a) a 12-17-2018 E-mail, in which RP made yet another request to licensee for the written report, and b) a 12-17-2018 E-mail reply to RP, in which licensee promised to release the written report to RP on 12-18-2018. Two (2) of two (2) facility managers, who were involved in processing the request, said the report was released to RP “a couple of weeks” after 12-09-2018. All parties interviewed corroborated that the written report was eventually given to RP, but none could recall the precise date the release occurred. LPA was unable to obtain primary source evidence proving the actual date of the release. Nonetheless, the evidence revealed that even in a best-case scenario, licensee did not give the written report to RP prior to 12-18-2021.

Based on records reviewed and interviews, a preponderance of evidence exists, and the above allegations are substantiated. Deficiencies are cited per California Code of Regulations, Title 22; refer to the attached LIC 9099-D. Plans of Correction were jointly developed with Castile. An exit interview was conducted with the administrator, to whom a copy of this report, the LIC 811 Confidential Names list, and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20190909092657
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 CARMEL VALLEY
FACILITY NUMBER: 374603617
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2021
Section Cited
CCR
87465(a)(5)
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Incidental Medical and Dental Care: “The licensee shall assist residents with self-administered medications as needed.” This requirement is not met as evidenced by:
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Administrator shall arrange retraining for all nurses and medication technicians on recognizing verbal and non-verbal signs of pain. An agenda and training sign-in sheet shall be submitted to LPA by the POC due date.
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Based on record review and interviews, the licensee did not assist resident with self-administered medications as needed for 1 of 1 persons in care [R1], which posed a potential health risk to persons in care.
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Type B
10/23/2021
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements: “A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of occurrence of… (D) Any incident which threatens the welfare, safety, or health of any resident…” This requirement is not met as evidenced by:
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Responsible Party for R1 since received the written report. Administrator and Health and Wellness Director shall undergo retraining on 87211 Reporting Requirements, taught via an outside source. A training sign-in sheet shall be submitted to LPA by the POC due date.
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Based on record review and interviews, the licensee did not submit a written report to resident’s responsible party within seven days of the occurrence for 1 of 1 persons in care [R1], which posed a potential impact on the facility’s plan of operation.
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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: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4