435200913-6-6-2023-26-AS-RMAO-CUHJLR-20230808070910

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200913
Report Date: 06/06/2023
Date Signed: 06/06/2023 03:51:56 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/15/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20230515103428

FACILITY NAME:	BROWNELL CARE HOME III		FACILITY NUMBER:	435200913
ADMINISTRATOR:	BROWNELL, MYRNA		FACILITY TYPE:	735
ADDRESS:	1510 RUE AVATI DRIVE		TELEPHONE:	(408) 923-1765
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95131
CAPACITY:	6	CENSUS: 5	DATE:	06/06/2023
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Administrator Myrna Brownell		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff is refusing to accept client back to the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator Myrna Brownell.

On 5/15/2023, the Department received a complaint that staff refused to accept resident (R1) back to the facility after resident was admitted to the hospital. The Department also received an Incident Report for R1 which took place on 5/11/2023 when staff were not able to redirect R1 and left the facility. R1 was found and was taken to EPS for evaluation.

Page 1 of 2, please see LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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 3

Control Number 26-AS-20230515103428

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BROWNELL CARE HOME III	FACILITY NUMBER: 435200913
	VISIT DATE: 06/06/2023

NARRATIVE

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On 5/15/2023, the Department was notified the facility was not accepting resident back after discharge from EPS due to not having enough staff to support R1's elopement. The facility is a level 4 facility and should be able to meet R1's needs.

On 5/16/2023, the Department conducted an initial investigation and interviewed Administrator, and staff. R1's records, including Preplacement Appraisal Information, Functional Capability Assessment, and staff progress note from 5/1/2023-5/11/2023. Four staff members were on duty, including Administrator and 1 staff members was live-in staff who was off from duty observed at the facility.

Based on Physician's Report, R1 is able to leave the facility unassisted. Based on interview with the Administrator (ADM), the resident had a history of AWOL and ADM was aware of his exiting behaviors. Interviews with S1-S3, R1 has asked to go to 7/11 at least once day and staff were able to re-direct R1. During interview with ADM, ADM accepted that the facility continued with the accepting R1 without creating a care plan.

When ADM discussed R1's admission to the hospital and EPS on 5/15/2023 ADM stated she did receive two calls from EPS from two different Registered Nurses to pick up R1 but ADM refused to pick up R1 over the phone. ADM stated "I did not want to take the resident back. I'd rather take the citation than to accept the resident back to the facility". ADM stated she did not assess the resident prior to admitting the resident to the facility.

The Department has conducted an investigation of the above allegation. Based on interviews and records review, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D.

Exit interview conducted with Administrator Myrna Brownell. A copy of this report, along with the facility's appeal rights were provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20230515103428

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BROWNELL CARE HOME III	FACILITY NUMBER: 435200913
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/13/2023 Section Cited CCR 85068.1(c)(2)	1 2 3 4 5 6 7	85068.1 Admission Procedures (c)Prior to accepting a client for care and supervision, the person responsible for admissions shall:(2) Develop a Needs and Services Plan as specified in Sections 80068.2 and 85068.2. This requirement is not met evidenced by:	1 2 3 4 5 6 7	Administrator will submit a written plan on understand regulation, policy and procedure on admitting resident to the facility by POC date.
	8 9 10 11 12 13 14	Based on interview and record review, Administrator stated R1 was admitted to the facility without developing a needs and services plan which poses a potential Health, Safety, or 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: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC9099 (FAS) - (06/04)

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