Brookdale Chanate

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: -Staff not keeping an accurate record of resident’s payments.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver the findings regarding the above allegation and met with Administrator Patricia Gustin. The Department received an allegation of staff not keeping an accurate record of residents’ payments. Per Reporting Party when resident (R1) receives a bill for the month, R1 writes a check and walk it down to facility bookkeeper (S1) timely, but no receipt or acknowledgement is given to R1. However, the following month R1 would receive a late fee of $250.00, when R1 inquiries about it with S1 who instructs R1 to ignore it. Last month (May 2025), R1’s bill was $6,784.00 then receives a bill the following month for $13,985.52, and the responsible party doesn’t believe the facility is keeping an accurate record of R1’s payments resulting in late fees continuing to be added along with additional fees. Based on confidential interviews conducted with S1, last month (May 2025), there was a glitch inthe state’s words, verbatim · CDSS document, Jul 17, 2025 · control 21-AS-20250603083138

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff does not respond to pendant call system timely Staff left resident in soiled incontinence briefs for an extended period of time

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility deliver complaint findings on the above allegation. LPA met with Administrator Robert Alvarado. Complaint alleges staff does not respond to pendant call system timely. Complaint alleges that facility is short-staffed and so do not provide timely care. Per California Title 22, RCFEs do not have staffing ratios and staffing is dependant on residents' needs, so a determination that a facility is short-staff is determined by whether or not residents' needs are being met. At this facility, the method by which residents alert staff that they need help with care or require assistance is through a pendant call button system. Each resident is assigned a pendant. When a resident needs help or assistance with a care need, they push the button on their pendant in order to alert staff to their need. During investigation, LPA review of pendant log shows that between 2/9/25 and 2/13/25 residents pushed their pendant call buttons 1the state’s words, verbatim · CDSS document, Mar 5, 2025 · control 21-AS-20250127104841

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility did not provide resident's authorized representative with the correct refund Facility billed resident's authorized representative after resident's departure from facility for incontinence items

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings for the above allegations. LPA met with Robert Alvarado, Administrator. Compliant alleges facility did not provide resident's authorized representative with the correct refund. Per R1’s admission agreement, the agreement will terminate upon death. The estate will be responsible for all outstanding fees due at the time of death until personal property is removed from the Brookdale apartment, within 15 days after the personal property is removed from the apartment, R1’s estate will receive a refund of any fees paid in advance. LPA review of Brookdale’s account history for R1 shows that on 7/3/24 R1’s responsible party paid the full amount of rent covering the period of 7/1/24-7/31/24. During investigation, LPA received proof of the removal of R1’s personal belongings on 7/10/24 as evidenced by the paid invoice from removal company. R1 passed away on 7/13/24. Continued on 9099C... Substthe state’s words, verbatim · CDSS document, Jan 9, 2025 · control 21-AS-20241114141725

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Licensee failed to administer medications as prescribed by physician

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegations. LPA met with Robert Alvarado, Administrator. Complaint alleges licensee failed to administer medications as prescribed by physician During investigation, LPA reviewed resident's (R1) physician's orders, electronic MAR (eMAR), and Medication Administration Audit report. R1's medication list as of 11/25/24 listed Sevelamer Carbonate 800mg 1 tablet 3 times per day. R1 was discharged from a hospital stay on 12/6/24. LPA review of 12/6/24 discharge papers have medication orders for Sevelamer 800mg 1 tablet 3 times per day. Continued on 9099C... Substantiatedthe state’s words, verbatim · CDSS document, Dec 27, 2024 · control 21-AS-20241217154914

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility did not notify responsible party of resident's change of condition Facility did not seek timely medical for resident in care

At approximately 1:45pm, Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to deliver findings regarding the above allegations and met with Heidi Gallagher, Director of Health and Wellness (DHW). Temporary Administrator Alex Baiasu contacted by phone and gave permission for DHW to sign. During investigation, the Department conducted interviews and reviewed documents including, but not limited to, medical records and facility records. Facility did not notify responsible party of resident's change of condition, Facility did not seek timely medical for resident in care - Complaint alleges that prior to their passing, resident, R1 had stopped eating for 5 days and had been refusing medications as well but the responsible party was not notified, and facility did not seek timely medical care. Continued on 9099C... Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 11, 2024 · control 21-AS-20230921102025

Allegation investigated: Staff are not following a resident's needs and services plan

At approximately 8:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Health and Wellness Director, Heidi Gallagher, and Interim Executive Director, Alex Baiasu. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff are not following a resident’s needs and services plan.” Complainant alleged that facility did not follow Resident 1 (R1’s) care plan by not changing or rotating them enough and stated that facility staff were to change and rotate R1 every two hours. Review of R1’s file indicated that they were admitted to Hospice on 12/26/2023. Review of R1’s Personal Service Plan, dated 01/04/2024, stated R1 was to be checked and changed approximately every 3 to 4 hours. Continued on LIC9099C Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 11, 2024 · control 21-AS-20240118085437

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not repair a resident's pull cord device Staff did not respond timely to a resident's alerts

At approximately 10:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegations and met with Business Office Manager, Danielle Oseguera. During the course of the investigation, LPA requested and reviewed documents, and conducted interviews. There are allegations that staff did not repair a resident's pull cord device and that staff do not respond timely to a resident's alerts. Based on record review and staff interviews, LPA confirmed that some resident pull cords are in need of repair/replacing and were not operable when tested by facility staff. Staff interviews conducted stated that the facility's call system occasionally does not work. Staff interviews stated that sometimes residents will call for assistance, but the call does not always show up on the care staff's pagers. Care staff have started to check the facility's computer to see if any calls are appearing since it does not always appear on their pagerthe state’s words, verbatim · CDSS document, Jan 8, 2024 · control 21-AS-20231212163014

Allegation investigated: Facility failed to respond to resident's pendant/call button/phone calls

Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegation and met with Robert Alvarado. Facility failed to respond to resident's pendant/call button/phone calls - Complaint alleges that a resident pushed their pendant but staff did not respond. LPA confirmed through document review that there have been multiple occasions where residents' pendants were not responded to. A Civil Penalty in the amount of $250 is being assessed for repeaiting regulation 87411(a) more than once in a 12 month period. Based on record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Substantiatedthe state’s words, verbatim · CDSS document, Nov 30, 2023 · control 21-AS-20231030165241

Allegation investigated: Facility staff did not ensure that resident's call button is accessible Facility is not meeting the needs of resident in care

Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegation and met with Robert Alvarado. Facility staff did not ensure that resident's call button is accessible - Complaint alleges that pull cord in the resident's room is tucked behind their bed so resident does not see it. While conducting a walk through of the facility, LPA observed that the pull cord at the head of the bed for noted resident was pulled forward and laying on resident's bed. Continued on LIC9099C Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 30, 2023 · control 21-AS-20231023101800

Allegation investigated: Insufficient Staffing Facility is not ensuring that residents have incontinence supplies

Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegations and met with Robert Alvarado. Administrator, Katelyn Ledesma was unavailable during this visit. Insufficient Staffing - Complaint alleges that facility does not always have two caregivers to assist residents who need two people to transfer them. This allegation was supported by interviews and review of staff schedule indicating that staff do have shifts where they work by themselves. Facility is not ensuring that residents have incontinence supplies - Complaint alleges that there are not always sufficient incontinence supplies for residents. This allegation is supported by interviews indicating that while there may be backup supplies sometimes, there are not always backup supplies resulting in caregivers using other residents' supplies which are not always replaced. It is facility policy that incontinence supplies Continued on LIC9099C Substantiatedthe state’s words, verbatim · CDSS document, Nov 20, 2023 · control 21-AS-20230927100309

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility did not provide written incident report to responsible party

Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegation and met with Administrator, Katelyn Ledesma. Facility did not provide written incident report to responsible party - Complaint alleges that facility did not provide the resident's death report to their responsible party. Interviews revealed that facility did not provide report because the facility was unable to determine whether the responsible party had authority to receive the report. LPA's review of R1's Admission Agreement and interviews revealed that the death report was not provided to the individual who signed the Admission Agreement. Continued on LIC9099C Substantiatedthe state’s words, verbatim · CDSS document, Nov 6, 2023 · control 21-AS-20230921102025

Allegation investigated: Residents' pendants are not working Staff do not help residents in a timely manner

Licensing Program Analyst Victoria Bertozzi arrived unannounced to deliver findings regarding the above complaint allegations and met with Health and Wellness Director, Heidi Gallagher. During investigation LPA conducted interviews with staff, residents and other interested parties, reviewed documents and made observations. Residents' pendants are not working - Complaint alleges that the call bell system that includes the pendants was not working for multiple weeks. LPA confirmed through multiple staff and resident interviews that the call button system was down for multiple weeks. Facility has since had system repaired. Continued on LIC9099C Substantiatedthe state’s words, verbatim · CDSS document, Oct 23, 2023 · control 21-AS-20230914133321

Allegation investigated: Facility did not meet resident's needs Facility did not follow resident's care plan Facility did not respond to call buttons Facility staff did not ensure that resident received warm food Facility did not properly respond to resident's injuries

Licensing Program Analysts Bertozzi and Coppo arrived unannounced to complete complaint investigation regarding the above allegations and met with Administrator, Katelyn Ledesma. Facility did not meet resident's needs, Facility did not follow resident's care plan – Complaint alleges that resident requires assistance with meals and catheter care in the form of the catheter bag being emptied and meals being delivered. Per complainant, the catheter bag was to be emptied three times per day and there were multiple occasions where the catheter bag was not emptied timely noting two occasions where the resident’s catheter came out requiring a nurse to come to the facility and re-insert the catheter. Complainant reported that the catheter may have come out as a result of the bag being overfull. Per interview with individual involved with resident’s care, the catheter line could have come out from the catheter bag being overfull but it is not clear if that was the reason in this case. Continuedthe state’s words, verbatim · CDSS document, Oct 3, 2023 · control 21-AS-20230714123714