Brookdale Loma Linda

Allegation investigated: Staff did not meet residents incontinent needs Due to staff negligence, resident sustained pressure injuries Staff did not provide authorized representative copies of residents records Staff did not assist with ensuring home health nursing and physical therapy occurred timely Staff handled resident in a rough manner

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPA met with Executive Director Maritza Lujan, and discussed the purpose of the visit. Regarding Allegation #1, that staff did not meet residents’ incontinence needs, Resident #1 (R1) was unable to be interviewed due to no longer residing at the facility. The LPA conducted interviews with five (5) residents. Three (3) residents stated they do not require incontinent care but are able to request assistance if needed. The remaining two (2) residents were unable to provide responses. LPA also interviewed five (5) staff members. All five (5) staff reported that they attend to residents’ incontinence needs by checking and changing residents approximately every two (2) hours. The Executive Director stated that staff receive daily assignments and are aware of which residents require incontinence assistance. Unsubstantiated Regarding Allegation #2, that due to staff negligence R1 sustained pressure injuries, R1 was unable to be interviewed because they no longer reside at the facility. Review of R1’s care plan indicates R1 was not bedridden and was capable of repositioning independently. LPA interviewed five (5) staff members. The Executive Director reported that R1 was originally admitted to the hospital for a rash, which was later diagnosed as chicken pox. While hospitalized, R1 was noted to have redness in the coccyx area, which was documented as a Stage 1 pressure ulcer. Four (4) staff members reported they have not observed residents developing pressure injuries due to staff neglect, stating that when even minor redness is observed, ointment is applied promptly to prevent further irritation. Regarding Allegation #3, that staff did not provide the authorized representative with copies of the resident’s records, review of R1’s file confirmed that R1 was their own responsible party and had not requested copies of their records. The LPA conducted interviews with four (4) staff members. All four (4) reported that when responsible parties request resident records, they are referred to upper management for assistance. Regarding Allegation #4, that staff did not assist in ensuring home health nursing and physical therapy services were provided in a timely manner, the Executive Director reported that the facility is not responsible for arranging home health or physical therapy services. It was recommended that R1 have these services coordinated prior to discharge from the skilled nursing facility to Brookdale Loma Linda. Interviews with two (2) additional staff confirmed that home health nurses are expected to check in at the medication room or Health and Wellness office to provide updates on the residents they visit. Regarding Allegation #5, that staff handled the resident in a rough manner, LPA conducted interviews with five (5) residents. All five (5) residents reported that staff do not handle them roughly. LPA also interviewed four (4) staff members, all of whom stated they do not handle residents roughly and have not observed other staff handling residents in a rough manner. Based on observation, interviews, and pertinent documents the allegations are unsubstantiated. An Unsubstantiated complaint means, that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Executive Director Maritza Lujan and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 1, 2026 · control 56-AS-20260205162857

Type of visit: Required - 1 Year

On Wednesday, February 4, 2026, Licensing Program Analysts (LPAs), Andrew Martinez and Sarina Ramirez, made an unannounced visit to the facility to conduct a required annual inspection. LPAs met Executive Director, Maritza Lujan, and discussed the purpose of the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (220) and current census of (115). LPAs were accompanied by Maintenance Director, William Cruz, to conduct a tour and general inspection of the facility which included but was not limited to the following: Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming poosl or similar bodies of water. The facility has sufficient space for residents’ activities. Six (6) resident bedrooms and bathrooms were inspected. Hot water temperatures in the 6 residents' rooms measured at 110.0 °F, 106.0°F, 107.4°F, 105.0°F, 108.0°F, and 112.4°F degrees Fahrenheit (°F). The facility is equipped with operating smoke alarm/carbon monoxide detectors, recently inspected at time of last fire drill completed by FDS Fire Drill Service on December 9, 2025 (12/09/25). Facility has operating laundry equipment, and telephone service. The facility has Personal Rights, Facility Sketch, Community Care Licensing Complaint, and Ombudsman posters, emergency telephone numbers, daily menu, activities memo, and facility license posted visibly in a common area. LPAs observed a resident's laundry detergent was left accessible to residents in care in the facility's laundry room after use by housekeeper. Bottle was immediately stored away by housekeeping staff. A Technical Violation will be issued. Food Service: Kitchen and dining areas were maintained cleaned. Perishable and nonperishable food supplies were observed sufficient for number of residents in care. Facility refrigerators and freezers were maintained in operating condition. Sharps were observed kept locked and inaccessible to resident in care. Health Related services: LPAs reviewed six (6) resident medications. Resident’s medications are labeled and centrally stored in a locked room. Record Review: Eight (8) resident files reviewed were observed to be complete. Eight (8) staff files reviewed were observed to be complete. The facility has a recently reviewed Emergency and Disaster Plan, signed January 6, 2026 (01/06/26), and Infection Control Plan, signed January 21, 2026 (01/26/26), on file. The facility's liability insurance was observed current in compliance with Health and Safety Code (HSC) regulations. Based on LPAs observations and records reviewed, a technical violation, with no deficiencies, is being cited per Title 22, Division 6, of the California Code of Regulations (CCR). An exit interview was conducted and a copy of this Facility Evaluation Report LIC 809, LIC 809-C, LIC 9102, and letter of Appeal Rights were discussed with and provided to Executive Director, Maritza Lujan, at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 4, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained bruise from staff while in care Staff is not responding to resident call pendants in a timely manner Staff is not treating resident with dignity and respect Staff did not change resident's diaper in a timely manner

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to deliver findings on a complaint investigation regarding the above allegations. LPA met with Executive Director Maritza Lujan and discussed the purpose of the visit. Regarding Allegation #1, it was alleged Resident 1 (R1) sustained a bruise from staff while in care. R1 moved out of the facility in November 2024 and was unavailable to be interviewed. LPA interviewed 11 residents, which all informed LPA they have not sustained bruising from staff. LPA interviewed 5 staff, which all have informed LPA they have not left brusies on residents, nor have they seen or heard of other staff leave bruises on residents. Regarding Allegation #2, LPA interviewed 11 residents, 4 out of 11 residents informed LPA staff respond to call pendant in a timely manner. 1 out of 11 residents informed LPA staff do not respond to call pendant in a timely manner. 4 out of 11 residents informed LPA they are independent and never had to use their call pendants. 1 out of 11 residents informed LPA staff sometimes respond to call pendant in a timely manner. Unsubstantiated 1 out of 11 residents was nonverbal and unable to answer whether staff respond in a timely manner to call pendant. As LPA interviewed a resident in their room, their call pendant was pushed and tested. LPA observed staff respond to the call pendant in 5 minutes and 30 seconds proving staff attend to call pendant in a timely manner. LPA interviewed 5 staff, which all have stated they respond to call pendants in a timely manner, they all try to respond to calls within 10 minutes max. Regarding Allegation #3, staff interviewed 11 residents. 10 out of 11 residents informed LPA staff treat them with dignity and respect. 1 out of 11 residents informed LPA some staff but not all treat them with dignity and respect. LPA interviewed 5 staff, which all have stated they treat residents with dignity and respect. Regarding Allegation #4, LPA interviewed 11 residents. 6 out of 11 residents informed LPA they do not use diapers. 2 out of 11 residents informed LPA they change their own diapers. 1 out of 11 residents informed LPA staff change their diaper in a timely manner. 1 out of 11 residents informed LPA staff do not change their diaper in a timely manner. 1 out of 11 residents was nonverbal and unable to answer whether or not they used diapers or if staff change in a timely manner. Based on observation, interviews, and pertinent documents the allegations are unsubstantiated. An Unsubstantiated complaint means, that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Executive Director Maritza Lujan and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 28, 2025 · control 56-AS-20220920133432

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano made an unannounced visit to the facility to conduct a required annual inspection. LPAs met Executive Director Maritza Lujan and discussed the purpose of the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (220), and a current census of (106). LPAs conducted a general inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pool or similar bodies of water. The facility has sufficient space for resident activities. Five (5) resident bedrooms were inspected. Five (5) resident’s bathrooms were inspected, hot water temperatures measured 110.1 degrees F. The facility is equipped with operating smoke/carbon monoxide alarms, the facility was recently inspected by the Fire Department on 02/14/25. Facility has operating laundry equipment, and telephone service. The facility has posted in a common area, personal rights, facility sketch, the Community Care Licensing complaint poster, Ombudsman poster, menu, activities, and license. Cleaning supplies were kept inaccessible to residents in care. Food Service: Kitchen and dining areas were maintained cleaned. Perishable food supply is sufficient for number of residents in care, however nonperishable food supply is not sufficient for a seven (7) day supply, deficiency will be issued . Facility refrigerators and freezers were maintained in operating condition. The facility has posted a monthly menu. Sharps were not kept locked, deficiency will be issued. Continuation on LIC809-C Health Related services: LPAs reviewed (6) resident medications. Resident’s medications are labeled and centrally stored in a locked room. Record Review: Ten (10) resident files reviewed were observed to be complete. Eight (8) staff files reviewed were observed to be complete. The facility has an emergency and disaster plan on file; last disaster drill was completed on 02/20/25. Based on LPAs observations and records reviewed, deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report (LIC809) and LIC 809D was discussed to Executive Director Maritza Lujan . Copies of the reports were provided with appeal rights to the Executive Director at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 25, 2025

Allegation investigated: Facility staff inappropriately touched a resident in care

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to deliver findings on a complaint investigation on the above allegation. LPA met with Executive Director Maritza Lujan, and discussed the purpose of the visit. The investigation consisted of file review and interviews with relevant parties, regarding the allegation facility staff inappropriately touched a resident in care, LPA conducted 4 staff interviews, 4 out of the 4 staff informed LPA they have not touched residents inappropriately nor have they heard of other staff touching residents inappropriately. LPA conducted 5 resident interviews, 4 out of the 5 residents informed LPA they have not been touched inappropriately by staff. 1 out of the 5 residents no longer resides at the facility however, during their time at the facility they were not touched inappropriately by staff. Unsubstantiated Based on LPAs observations, record review, and interviews, the above allegation is Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and a copy was provided to Executive Director Maritza Lujan at the conclusion of the visit.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 56-AS-20240814131711

Allegation investigated: Staff handled resident in a rough manner Staff not treating resident with respect Staff left resident unattended for multiple hours

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPA met with Executive Director Maritza Lujan, and discussed the purpose of the visit. Regarding allegation #1, LPA conducted 3 staff interviews, 3 out of the 3 staff informed LPA S#1 had handled R#1 in a rough manner. Executive Director followed the proper reporting requirements notified CCLD and the local Police Department, S#1 has been placed on suspension since 11/16/24 pending an internal investigation. LPA conducted 5 resident interviews, 1 out of the 5 residents informed LPA S#1 handled resident in a rough manner, 4 out of 5 residents informed LPA staff does not handle them in a rough manner. Substantiated Regarding allegation #2, LPA conducted 3 staff interviews, 3 out of the 3 staff informed LPA they treat residents with respect; however S#1 did not treat R#1 with respect. LPA conducted 5 resident interviews, 1 out of the 5 residents informed LPA S#1 was always rude to them however, all other staff treat them with respect. 4 out of the 5 residents informed LPA staff treat them with respect. Regarding allegation #3, LPA conducted 3 staff interviews, 3 out of the 3 staff informed LPA they do not leave residents unattended however, 2 out of the 3 staff informed LPA S#1 had left R#1 and R#2 unattended for a long period of time. LPA conducted 5 resident interviews, 2 out of the 5 residents informed LPA they have been left alone for a long period of time by S#1 however, no other staff have left them unattended. 3 out of the 5 residents stated they are independent but have never been left unattended when help was needed. Based on the evidence gathered during the investigation, the above allegations are Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Personal Rights 87468.1 (a) from division 6, chapter 8, article 8 is being cited on the attached LIC 9099 D. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights and LIC 9099D to Executive Director Maritza Lujan.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 56-AS-20241121111551

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87468.1(a) · Plan of correction due date: Dec 14, 2024

87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity...(2)To be accorded safe...(3)To be free from punishment... This requirement is not met as evidence by: Based on interviews, the Administrator did not ensure Personal Rights to be met for residents, which poses an immediate Health, Safety, or Personal Rights risk for people in care.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: Administrator has agreed to review Personal Rights Regulation Provide training to all staff support .Licensee will ensure that training is signed and dated by all support staff and email proof to LPA by POC date.

Allegation investigated: Facility staff threatened resident with eviction Resident was not accorded dignity in relationships with other residents.

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to conclude the investigation on the above allegations. Regarding the allegation, facility staff threatened resident with eviction, there is not enough evidence to corroborate that resident #1 (R1) was threatened with an eviction. Regarding the allegation, resident was not accorded dignity in relationships with other residents, there is not enough evidence to corroborate this allegation. Based LPA observations, review of pertinent documents, staff interviews, and resident interviews, the allegations are Unsubstantiated. An Unsubstantiated finding means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and a copy of this report with Appeal Rights was provided to Executive Director Lujan at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 21, 2024 · control 56-AS-20240126110636

Allegation investigated: Facility staff did not dispense resident's medication as prescribed

Licensing Program Analyst (LPA), Yolanda Delgado made an unannounced visit to the facility to deliver findings for a complaint investigation into the allegation listed above. During the investigation, LPA interviewed four (4) staff members and eight (8) residents. LPA reviewed pertinent documents pertaining to the allegation. LPA was unable to interview pertinent residents due to refusal. On July 30, 2021, Community Care Licensing received a complaint indicating that facility staff did not dispense resident’s medication as prescribed. It was reported facility staff stopped giving Resident #1 (R1) medication for an unspecified amount of days until the facility received R1’s new prescription. It was also reported that R1 had a current prescription that they were not distributing to R1. Additional witness visited the facility on May 21, 2022 Substantiated (continued from page 1) On May 30, 2022, it was also alleged that Resident #2 (R2) was given last antidepressant medication on May 20, 2022. Information from additional witness reported that refill medication was provided to the facility on May 5, 2022, but the medication was unable to be located. Information obtained from staff interviews stated that facility staff has always provided medication as prescribed. It was advised that Med Techs are responsible to distribute the medication to residents. It was also advised that the facility utilizes a program to document the distribution of medication and med techs are responsible to document the medication. Information obtained from additional witness stated that they visited the facility on May 21, 2022 and the facility was still not able to locate R2’s medication. Additional witness stated that they distributed R2’s medication due to having spare medication on their person. Additional witness stated she planned to provide medication to R2 on May 22, 202, but facility staff contacted additional witness and advised that the medication was located. Information obtained from record review of R1 Medication Administration Record, (MAR) revealed that R1 did not received prescribed medication on the following dates: 7/23/2021, 7/25/2021, and 7/26/2021. It was also observed that R2 did not receive prescribed medications on 5/21/2022. Based on interviews and observation, the allegation that the facility did not dispense resident medications as prescribed is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The facility will be cited for violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Sections 87465(c)(2). This poses a health and safety risk to clients in care. An exit interview was conducted with Maritza Lujan. A copy of the report, 9099-D, along with Appeal Rights were provided to Maritza Lujan.the state’s words, verbatim · CDSS document, Feb 15, 2024 · control 18-AS-20210730133208

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2 · Plan of correction due date: Feb 15, 2024

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need...but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.the state’s words, verbatim · CDSS document, Feb 15, 2024

Plan of correction: Administrator stated the facility has implemented medication refill log for the past 1 year, nurses conduct quality assurance audits, Omnicare provides pharmacy audit and provides to facility quarterly.

Allegation investigated: Facility staff did not ensure that resident's medication was refilled in a timely manner Facility staff failed to report changes to resident's POA Facility charging resident for additional services

Licensing Program Analyst (LPA), Yolanda Delgado made an unannounced visit to the facility to deliver findings for a complaint investigation into the allegations listed above. During the investigation, LPA interviewed four (4) staff members and eight (8) residents. LPA reviewed pertinent documents pertaining to the allegations. LPA was unable to interview pertinent residents due to refusal. On July 30, 2021, Community Care Licensing received a complaint indicating facility staff did not ensure that resident’s medication was refilled in a timely manner, facility staff failed to report changes to resident’s Power of Attorney, and facility was charging resident for additional services. (continued on page 2) Unsubstantiated (continued from page 1) In regards to the allegation that facility staff did not ensure resident’s medication was refilled in a timely manner, Resident #1 (R1)’s POA stated the facility ran out of R1’s anxiety medication and didn’t notify POA. On May 14, 2022, It was also advised that Resident #2 (R2) medications were running low. LPA conducted interviews with Staff #1 (S1), #2 (S2), #3 (S3), #4 (S4) and information obtained from staff interviews reveal that medications were refilled in a timely manner by staff. Interview with Resident #3 (R3) revealed that medications have been refilled in a timely manner by family members, resident preferred pharmacy and residents R4, R6, R7, R8 not on the medication management program. LPA reviewed R1 and R2’S admissions agreement and the care plan revealed that the facility would order and coordinate medications between the family, health care providers and pharmacy. R1 & R2’s responsible party would refill the medication and bring to the facility. The facility would provide attention and/or assistance with taking medications, assist with medication storage. In regards to the allegation that the facility staff failed to report changes to resident’s Power of Attorney. It was reported that Resident #1 (R1)’s had a prescription change for medication and the facility did not notify the Power of Attorney. LPA conducted interviews with Staff #1, #2 (S2), #3 (S3), #4 (S4) and information obtained from staff interviews did not reveal that staff failed to report changes to resident’s Power of Attorney. Interviews with Resident #3 (R3), R4, R5, R6, R7, R8, R9 revealed that if there were any changes of condition and care for residents, Power of Attorney would be notified. R1’s Medication Administration Records for April 2021, May 2021, June 2021 and July 2021 did not reveal changes in medications. (continued on page 3) (continued from page 2) In regards to the allegation that the facility was charging resident for additional services. It was reported that R1 was paying extra for Medication Management that includes order and coordinate medications between the family, health care providers and pharmacy, the facility would provide attention and/or assistance with taking medications, assist with medication storage. On May 31, 2022, it was reported that R2 is paying extra for medication management. LPA conducted interviews with Resident #1 (R1), #2 (R2), R4, R5, R6, R7, R8, R9 and the interviews revealed that R1, R2, and R3 are on a medication management program and R1 and R2’s admission agreements and assessment summary observed the fees and the medication management services are being provided to R1 and R2. Interviews conducted with staff revealed that the facility provided medication management services and there is a fee. Based on interviews conducted and observations, the preponderance of evidence standard has not been met. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegations is unsubstantiated. An exit interview was conducted, and a copy of this report was provided along with LIC811 – Confidential Names List.the state’s words, verbatim · CDSS document, Feb 15, 2024 · control 18-AS-20210730133208

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Maritza Lujan, Executive Director, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (220) and a current census of (110) residents in care. The facility has a hospice waiver for (20) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. The facility has sufficient indoor and outdoor space for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has operating carbon monoxide alarms, signal system, and telephone service. The (6) resident bathrooms inspected were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured between 105 and 112 degrees F. The (6) resident bedrooms inspected had sufficient bed linen, lighting and furniture in good repair. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, facility license, resident's personal rights, and disaster evacuation plan and emergency telephone numbers. Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas. Care & Supervision: Facility has 24-hour/ 7-days a week care staff. Record Review: (5) staff files reviewed were observed to be complete and included criminal record clearances or exemptions through the Department. (5) resident files reviewed were observed to be complete. Last emergency drill was conducted on 11/18/23. The Executive Director's certification expires on 4/12/2024. Medical Related Services: All medication is centrally stored and kept locked in the medication room. Based on LPA observations and record review, no deficiencies were cited during today’s visit. An exit interview was conducted where reports LIC809/LIC809-C/LIC9102 were discussed and a copies were provided to the Executive Director at the conclusion of the visit.the state’s words, verbatim · CDSS document, Dec 19, 2023

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.