Brookdale Sunwest

Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegation. LPA met with Juanita Jackson and explained the reason for the visit. The investigation consisted of the following: On 12/15/21 LPA Cuevas conducted an unannounced initial visit. On 12/21/21 LPA Cuevas conducted a subsequent visit and conducted a tour of the facility. On 11/7/25 LPA Flores contacted administrator and requested staff schedule for December 2021 and current, resident and staff roster. On 11/17/25 LPA Flores interview 1 staff. On 11/19/25 LPA Flores conducted interviews with 5 residents and 3 staff. The investigation revealed the following: Regarding allegation: Inadequate staffing resulting in residents falling while in care. It is alleged there is one staff caring for 20 residents. (CONTINUED ON LIC 9099C) UnsubstantiatedRead the full finding— CDSS inspection report, November 19, 2025 · control 18-AS-20211210110500

On August 06, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the unannounced facility and met with Licensee. LPA explained the reason for the visit was to provide findings for the complaint investigation. On October 15, 2024, Community Care Licensing received a complaint alleging, facility does not have adequate staff to meet resident’s needs. During the investigation, LPA conducted interviews, record reviews, and made observations pertaining to the listed allegation. Regarding the allegation facility does not have adequate staff to meet resident’s needs, it was reported that when residents are calling for staff through the signal system, residents are required to wait for more than 30 minutes due to a lack of available staff. When interviewed, Administrator, Theresa Ward denied the allegation. UnsubstantiatedRead the full finding— CDSS inspection report, August 6, 2025 · control 18-AS-20241015170006

Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to deliver the findings of the above allegation. LPA toured the facility and met with Associate Executive Director Logan Harrison. The investigation included interviews with facility staff, residents, and a confidential source. It was alleged that an unidentified abuser was hitting a resident. Regarding the allegation, “Resident was physically abused while in care,” LPA found that, through interviews conducted, Resident One (R1) was yelling wanting out of the facility, and at the same time, being hit by Resident Two (R2). Two caregivers were in the direct vicinity of the incident and were able to engage both R1 and R2 and were able to redirect them from the area. Both residents did not complain of injury and did not go to the hospital for any treatment as a result of the incident. Due to caregivers being able to diffuse the situation and no injury reported, LPA found that this allegation was UNSUBSTANTIATED. ARead the full finding— CDSS inspection report, January 20, 2023 · control 18-AS-20230106131409

On 12/28/21 Licensing Program Analyst (LPA) David Cuevas conducted an unannounced visit for the purpose of following up with investigating the allegations above. LPA identified self and was granted entree. LPA met with Associate Executive Director, Eloiza Castellanos who was informed of the purpose of visit. During this investigation LPA conducted the following: Staff and resident interviews, walkthrough of facility, resident record review, facility file review, and made observations. Regarding Allegation: Facility lacks sufficient staff to meet the needs of the residents in care. The department initiated an investigation due to reports that facility lacks sufficient staff to meet the needs of residents in care. SubstantiatedRead the full finding— CDSS inspection report, December 28, 2021 · control 18-AS-20211209160912

Licensing Program Analyst (LPA) conducted an unannounced visit to the facility in order to deliver findings for the above allegation. LPA met with Administrator, Theresa Ward, and discussed the purpose of the visit. The investigation consisted of records review and interviews with staff. LPA interviewed Staff #1 (S1) who stated that the facility conducted an internal investigation of the above allegation. According to S1, on 10/29/2020, Staff #2 (S2) grabbed Resident #1's (R1's) arm after attempting to retrieve Resident #2's (R2's) purse. According to S1, S2's actions resulted in R1 sustaining bruising to the arm. S1 stated that the facility had determined that S2's actions violated facility guidelines for appropriate conduct; therefore, S2 was terminated on 10/31/2020. Based on the evidence gathered during the course of the investigation, the above allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderanceRead the full finding— CDSS inspection report, July 20, 2021 · control 18-AS-20201030081423