Brookdale Irvine

Allegation investigated: Staff did not give proper notice to resident's designated representative of rate increases. Staff did not give resident's designated representative explanations for rate increases. Staff incorrectly billed resident for medications. Staff are not following resident's medication doctor's orders.

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted by Executive Director (ED) Shannon Howell. It was alleged that staff did not give proper notice to resident's designated representative of rate increases. LPA conducted an interview with the reporting party (RP) who stated that the current ED explained everything to RP regarding rate increases, of which RP also verified that the notice was received and provided timely. It was alleged that staff did not give resident's designated representative explanations for rate increases. LPA conducted an interview with RP and staff 1 (S1), of which both interviews verified that explanations were provided regarding the increases. Both interviews stated that resident 1 (R1) would order "tray service" to their room and was getting charged every time R1 utilized tray service. Unsubstantiated 1 of the interviews specified that prior management failed to charge R1 for tray services, and now that there is new management at the facility, the management is adhering to the protocol regarding the rate increases. RP also stated that R1 was notified about these increases due to the tray services, to which R1 was provided explanations and encouragement to not utilize tray services if R1 did not want to continue paying. LPA reviewed records and it was observed that prior management did not charge R1 for tray services and obtained verification from R1 that R1 had been utilizing tray services "all the time". It was alleged that staff incorrectly billed resident for medications. LPA conducted an interview with RP and S1 and it was revealed that R1 is being charged for a prescribed medication, however RP believes that R1 does not need it, therefore it should not be billed. The interview with S1 stated that the facility contacted R1's doctor to inquire about if R1's medication should be discontinued, to which the doctor declined and stated that the medication for R1 would be continued as needed. LPA reviewed records and it was observed that the medication chart for R1 is up to date and reflect the medications that are prescribed by the doctor. It was alleged that staff are not following resident's medication doctor's orders. An interview with S1 stated that RP believes what medications R1 should not have, however, S1 verified that the facility manages R1's medications. The medication RP believes should be discontinued is a pro re nata "PRN" of which S1 stated that the PRN medication is only given to R1 as needed per physician report. An interview was conducted with RP, who was unable to provide further information regarding this allegation. RP then requested LPA to "disregard" the allegations/complaint due to obtaining information and explanations from the facility. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with ED Howell. A copy of this report was explained and provided.the state’s words, verbatim · CDSS document, Oct 13, 2023 · control 22-AS-20230726101433

Allegation investigated: Facility allows resident's medication supply to run out Lack of staffing

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation(s). LPA met with Business Office Manager Sharin Belanger and Administrator (AD) Shannon Howell and explained the reason for today’s inspection. The investigation into the allegations of facility allows resident's medication supply to run out and lack of staffing revealed the following: During the course of the investigation, LPAs inspected the facility, interviewed AD, 3 staff, and 10 residents, and obtained and reviewed copies of the Resident Roster, Staff Schedule, Physician’s Report for Residential Care Facilities for the Elderly (Physician’s Report) for 13 residents, Medication Administration Records (MAR) for 10 residents, Weights and Vitals Summaries for 10 residents, the facility’s Diagnosis Report, an email dated 07/10/23 from AD to a prospective resident, and Hoag Hospital Irvine Medical Records dated 09/20/23. Substantiated Regarding the allegation that the facility allows resident's medication supply to run out: Per staff statements, facility medication technicians and nurses are trained to reorder once-a-day medications 7 days in advance and twice-a-day medications 14 days in advance to ensure medications do not run out. Medication audits are also regularly conducted. LPA interviewed AD and the Wellness Director who denied the allegation and stated there are no issues with medications at the facility. LPA interviewed 10 residents and 3 residents stated they received assistance with medications. LPA reviewed MARs for these 3 residents for the past 3 months and observed that 2 of these residents, Resident #1 (R1) and Resident #2 (R2), had missed doses of medications due to the facility running out of supply, including 6 missed doses of Sertraline HCl Tablet 100 MG, 2 missed doses of Klor-Con 10 Oral Tablet Extended Release 10 MEQ (Potassium Chloride), and 1 missed dose of Furosemide Oral Tablet 20 MG (Furosemide). Per the Mayo Clinic, Sertraline is used to treat depression and other psychiatric disorders and missing several doses of an antidepressant may cause discontinuation syndrome the symptoms of which include agitation, sleep disturbances, dizziness, and flu-like symptoms; Potassium Chloride is used to treat blood pressure issues and a lack of potassium may cause muscle weakness, irregular heartbeat, mood changes, or nausea and vomiting; and Furosemide is used to treat fluid retention and swelling caused by congestive heart failure and other conditions and should only be taken as directed by the patient’s doctor. Regarding the allegation of lack of staffing: It was alleged residents were left in their chairs in the same positions for extended periods, wellness checks are not being conducted, and residents’ food intake is not being monitored properly resulting in weight loss. LPA interviewed AD who denied the allegation and stated that the facility has been using staffing agencies to fill in any staffing gaps since 2020. When interviewed, the Wellness Director denied the allegation and stated that staffing at the facility is based on a system which calculates how many service hours are required daily by the care plans of the residents and determines the number of staff needed. For example, on 08/23/23, the staffing schedule was 3 caregivers and 1 medication technician for the morning shift, 2 caregivers and 1 medication technician for the afternoon shift, and 3 caregivers and 1 medication technician for the overnight shift, with the Wellness Director, Wellness Coordinator, and Residential Care Coordinator also scheduled. Staff interviewed stated that based on their care plans, not all residents receive wellness checks. Residents are able to use their pendant to call for assistance. Residents who have difficulty using the pendant are scheduled for regular wellness checks. LPA reviewed weight records for 10 residents which show that residents’ weight is closely and regularly monitored by the facility and that 2 residents lost enough weight to trigger warnings in the facility system and 1 of these residents has already regained weight. AD stated that AD, the Resident Care Coordinator, and the facility’s nurses conduct twice monthly meetings to discuss resident status and changes and to adjust the residents’ care plan if needed to address issues like weight loss. LPA interviewed 10 residents and none of the residents reported any issues with wellness checks, nutrition, or weight loss. However, 3 residents corroborated that the facility does not have enough staff and that the wait times for assistance after pressing the pendant can be as long as 1 hour and 15 minutes during busy periods. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations of facility allows resident's medication supply to run out and lack of staffing. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. Regarding the allegation that residents are not receiving services paid for: It was alleged residents were not taken out of their rooms for 3 months in 2020 but were paying additional fees to be escorted around the facility. LPA interviewed AD and facility staff who stated that care plans are created based on residents’ needs and, from these care plans, assignment sheets are created which specify what services the residents are to receive and at what frequency. All services are presumed provided unless the care staff reports that the resident refused the service. Refusals are documented in the resident’s progress notes and the facility will address the issue with the resident and their family. LPA interviewed 10 residents and none of these residents corroborated this allegation. Regarding the allegation that lack of care and supervision resulted in a resident's death: Per witness statements, on 05/26/20 Resident #3 (R3) had a pulse oxygen reading of about 95%. R3’s pulse oxygen was not read again until 05/28/20 when R3 called for assistance with complaints of nausea and vomiting at which point their pulse oxygen was checked again and read at 82%. R3 was taken to the hospital where they passed away on 06/01/20. Per staff statements, R3’s primary diagnosis was hypertension with congestive heart failure, R3 was not on hospice, R3’s passing came as a surprise, and R3’s cause of death was respiratory failure related to their congestive heart failure. LPA reviewed R3’s Physician’s Report dated 03/22/18 which states R3’s diagnoses included congestive heart failure, coronary artery disease, and mild cognitive impairment. R3’s Physician’s Report also states that R3 was ambulatory, able to follow instructions, able to communicate needs, able to leave the facility unassisted, able to store and administer their own medications, and had a do-not-resuscitate order but was not on hospice. LPA reviewed Hoag Hospital Irvine Medical Records dated 09/20/23 which state on page 11 that R3 had a history of congestive heart failure, a pacemaker, recurrent pneumonias and bronchitis and that R3 was taken to the hospital on 05/28/20 due to hypoxia after facility staff tested R3’s pulse oxygen at 70%. On pages 17 and 18, the Medical Records indicate that, while having a pulse oxygen of 70%, R3 did not express any shortness of breath and was speaking clear and complete sentences. Per page 35 of the Medical Records, at the hospital R3 stated that, overall, they have been in very good health. However, assessment at the hospital revealed R3 was “profoundly hypoxic” and had “severe sepsis.” On page 47, the Medical Records describe that despite aggressive measures in the Critical Care Unit, R3’s condition deteriorated and R3 and their family decided to start comfort care in lieu of additional aggressive treatment. Per page 65 of the Medical Records, R3 passed away on 06/01/20 at the hospital. The Medical Records do not indicate that hospital staff suspected neglect or lack of care at the facility. The hospital social worker’s assessment on page 61 of the Medical Records states only that R3 lived with their spouse at the facility, had an “independent” level of function, and that the social worker found no “discharge barriers” if R3 were to be returned to the facility. On page 381, the Medical Records indicate that R3 denied having concerns about the facility. No information was obtained indicating that R3 required regular wellness checks or pulse oxygen readings and no reports were received from the hospital, R3’s family, or R3 themselves regarding any concerns about R3’s care at the facility. Regarding the allegation that the facility failed to report an incident as required: It is alleged the facility accepted a resident back from a skilled nursing facility with a diagnosis of Clostridioides Difficile and failed to report it. LPA interviewed AD who denied this allegation. LPA interviewed the Wellness Director who denied this allegation and stated that the facility requires a negative test result or documentation that the infection has colonized before accepting a resident who was diagnosed with Clostridioides Difficile. The Wellness Director compiled a Diagnosis Report from the facility’s electronic medical record system showing all diagnoses of all residents at the facility. LPA reviewed the Diagnosis Report which does not include Clostridioides Difficile. No information was obtained corroborating this allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegations that residents are not receiving services paid for, lack of care and supervision resulting in resident's death, and failure to report incident as required occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. Regarding the allegation that the facility falsifies records: It was alleged the facility cannot accept residents with dementia and the facility ensures none of the residents have a dementia diagnosis by paying the 2 pre-contracted doctors $250 to falsely state that residents do not have dementia on their Physician’s Reports. LPA interviewed AD and the Wellness Director who denied the allegation and stated physician’s reports are completed by residents’ primary care physicians because they have history with these residents. LPA reviewed Physician’s Reports for 13 residents which showed that they were completed by 12 different doctors (2 residents who are related used the same doctor). LPA interviewed 10 residents none of whom provided information corroborating this allegation. AD stated the facility does not accept new residents with dementia and provided an email dated 07/10/23 in which she rejected a prospective resident for having a dementia diagnosis and referred them to facilities with memory care units. AD also stated that current residents who develop dementia are allowed to age in place and continue to live at the facility as long as their assessments indicate their needs can be met at the facility. LPA reviewed the facility’s file and confirmed that the facility is able to accept and retain residents with dementia, meaning the alleged falsification of Physician’s Reports would not even be necessary. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 22-AS-20200610155521

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 10, 2023

87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure 2 out of 3 residents received assistance with medications when the facility ran out of supply, which poses an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: The licensee stated they will create a plan to ensure that medication supply does not run out and submit the plan to LPA by POC due date and will train all medication technicians on the plan and submit proof to LPA within 7 days.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 23, 2023

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure sufficient staffing when residents had to wait up to 1 hour and 15 minutes for assistance after calling, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: The licensee stated they will review call wait time records, create a plan to ensure wait times are not excessive during busy periods, and submit the plan to LPA by POC due date.

Allegation investigated: Facility has pests. Staff failed to provide adequate food service.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegations received on 07/24/23. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Shannon Howell. LPA explained the reason for the visit. On today’s visit LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation that facility has pests, the following was revealed: Seven of eight individuals interviewed denied the allegation. The remaining individual reported seen a rat in the the lounge area during mid-July. During the course of the investigation LPA reviewed documents including the Ecolab Service Inspection Reports for June and July 2023. Two of two Ecolab Service Reports state the following: "Inspected and treated selected areas. Pest Activity Found." During the initial visit on 07/26/23 LPA toured the kitchen and observed rat traps on the corners of the kitchen floor. CONTINUED ON 9099-C... Unsubstantiated It was reported via interviews by Staff 1 (S1) that the rat traps were placed in the kitchen by the Pest Control company for pest prevention. During the interviews with residents it was reported that they have never seen a rat, a mouse and/or rodents in the facility. Regarding the allegation that staff failed to provide adequate food service, the investigation revealed the following: Four of five residents interviewed denied the allegation. Per interviews conducted with residents it was reported that the facility provides residents with warm quality food and/or enough food. Per interviews conducted with residents it was reported that the food can be cold sometimes. It was reported via interviews with staff that staff have not failed to provide hot food and/or provide adequate food for the residents. Based on LPA's observation and information gathered during the investigation, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, the allegations are deemed UNSUBSTANTIATED. LPA Ramirez conducted an exit interview with ED Howell and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 11, 2023 · control 22-AS-20230724102229

Type of visit: Case Management - Other

On this day Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced visit to deliver an amended report dated 07/26/23 in conjunction with complaint 22-AS-20230724102229. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Shannon Howell. An exit interview was conducted with ED Howell and a copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, Sep 11, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Celine De Perio conducted a case management visit to the facility in conjunction with complaint: 22-AS-20221220140629. LPA De Perio explained reason for visit and was greeted by Executive Director (ED) Shannon Howell. During the course of the investigation, it was requested on 01/04/2023 with Operational Specialist/Acting Executive Director at the time, to provide the following documents to Community Care Licensing (CCL). The following documents were requested on 01/04/2023, however were not provided: Facility internal investigation Pendant reports Resident care notes Resident signed waiver For today's visit, citations were issued. An exit interview was conducted with ED Howell. A copy of this report and Appeal Rights were provided and explained.the state’s words, verbatim · CDSS document, Aug 9, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 8775(c) · Plan of correction due date: Aug 16, 2023

87755 Inspection Authority of the Licensing Agency (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours... This requirement is not met as evidence by: Based on record reviews and interviews, licensee did not comply with the regulation cited and did not provide CCL staff with the requested documents. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 9, 2023

Plan of correction: Facility is to review the regulation cited and provide proof of understanding to LPA on or by 08/16/2023.

Allegation investigated: Staff failed to obtain medical care in a timely manner for resident who sustained serious injuries after an unwitnessed fall. Resident was left unattended for an extended period of time

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver findings for the complaint received on 12/20/23. LPA arrived at the facility and explained the purpose of today’s visit and was greeted by executive director (ED) Shannon Howell. The complaint was investigated by the Department which involved interviews and pertinent records review. It is alleged that the staff failed to obtain medical care in a timely manner for resident who sustained serious injures after an unwitnessed fall. The investigation revealed that on December 15, 2022, resident (R1) sustained a fall in their room and was not checked on until December 17, 2022. Staff (S1) even stated being “too busy” to check R1 because R1 was “always independent”. R1 personal service assessment plan dated April 5, 2022, stated that R1 has sustained a total of three falls within the past twelve months. Substantiated On R1’s physician report dated March 8, 2022, R1 was diagnosed with mild cognitive impairment. A fall risk assessment evaluation was conducted on April 5, 2022, and it was noted that R1 is a fall risk, and the three falls that were sustained in the span of twelve months, resulted in a hospitalization and with a fracture. On December 17, 2022, staff (S2) went to R1’s room and found R1 on the floor with a laceration on the head, was disoriented, and had dried blood covering their head. Per interview with the S2 upon finding R1 on the floor, it was observed that R1 also had two blood-soaked towels around their head and that R1 reported of having pain in the back of their head. The R1 reportedly had crawled to get towels. It was reported that R1 had “been there for a while as the blood on the towels was as hard as a rock”. On December 17, 2022, 911 was contacted to seek medical attention for R1. R1 was then admitted and evaluated at the hospital, and per hospital staff, R1 sustained injuries, was dehydrated, was soaked in urine, covered in blood and had feces all over. Hospital staff reported that through conversing with S2, S2 expressed being “terrified” because only two caregivers were on duty the night R1 was found. Due to R1 being left unattended from December 15, 2022 to December 17, 2022, the medical attention and care was delayed for R1 who sustained serious injuries: blunt head trauma, concussion, occipital scalp laceration, blunt chest and abdominal trauma and decubitus ulcers to her sacrum. It was alleged that resident was left unattended for an extended period of time. The investigation revealed that on December 15, 2022, R1 fell and called for help, however, did not receive any assistance from staff. R1’s friend called R1 via phone on December 16, 2022, and twice on December 17, 2022, and did not receive an answer, therefore contacted the facility and requested for a staff member to check on R1. On the evening of December 17, 2022, a staff member finally went into R1’s room based on the concerns that R1’s friend had expressed, and staff on duty discovered R1 laying on the floor and observed injuries and dried blood. There were no facility notes that indicated that staff did resident checks from December 15, 2022 to December 17, 2022. Interviewed staff were unaware of their own facility policy called a safety check policy which required caregivers to check in on their residents at least once at night between the hours of 10:00 p.m. and 6:00 a.m. If staff had checked on the R1, the R1 would not have spent two nights lying on the floor in their room in pain with injuries which required medical attention. Based on the information gathered during the investigation and review of documents obtained the preponderance of evidence standard has been met, therefore the allegations are determined to be SUBSTANTIATED. The following is being cited and the Immediate Civil Penalty has been assessed and issued per California Code of Regulations, Title 22 Division 6 Chapter 8, per H&S Code Section 1569.49(f). An exit interview was conducted with ED Howell. A copy of this report was explained, and appeal rights were provided during the visit.the state’s words, verbatim · CDSS document, Aug 3, 2023 · control 22-AS-20221220140629

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 4, 2023

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Based on the reviewed documents obtained and interviews conducted during the investigation, facility did not obtain timely medical care for seriously injured resident. This poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Aug 3, 2023

Plan of correction: As a plan of correction (POC), facility is to conduct an in-service training to all staff regarding the regulation cited.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Aug 4, 2023

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs…the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidence by: Based on the reviewed documents obtained and interviews conducted during the investigation, facility failed to ensure that the resident was regularly checked. This poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Aug 3, 2023

Plan of correction: As a plan of correction (POC), facility is to conduct a training with all staff regarding the regulation cited and will implement and document resident health and safety checks on a daily basis.

Type of visit: POC

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 06/02/2023. LPA De Perio explained reason for visit and was greeted by Executive Director (ED) Shannon Howell. *Deficiency cited under Health and Safety Code 1569.50 (a)(3) has been CLEARED. ED Howell conducted an in-service training to all the staff on the section cited, obtained signatures of the staff present, and provided proof of training to LPA. For this visit, no citations were issues. An exit interview was conducted with ED Howell. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Jun 14, 2023

Allegation investigated: Facility staff sexually assaulted resident in care

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver the findings for the above allegation. LPA met with Executive Director (ED) Shannon Howell and stated the purpose of the visit. On 10/4/22, an initial 10-day visit was conducted. The complaint was investigated by the Department. Findings are based upon this investigation which included record reviews and interviews. It is alleged that facility staff sexually assaulted resident in care. The investigation revealed that on September 13, 2022, resident (R1) reported that caregiver (S1) touched R1’s vaginal area in a sexual manner. It was later revealed that R1 discovered that S1 was making sexual advances with another resident, which led R1 to report the incidents to Executive Director. Substantiated Per Department interviews conducted with S1 regarding touching R1’s genital area, S1 stated “(I) told her not to tell anyone”. It was also revealed that the former management (Executive Director, Lead Nurse and Human Resource Department) were notified about S1’s history of inappropriate behavior, however, failed to report it and initiate any forms of disciplinary actions, and allowed S1 to continue to work at the facility. Based on the information gathered during the investigation and review of documents obtained the allegation is SUBSTANTIATED. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with ED Howell. A copy of this report was explained, and appeal rights were provided during the visit.the state’s words, verbatim · CDSS document, Jun 2, 2023 · control 22-AS-20221003131319

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.50(a)(3) · Plan of correction due date: Jun 9, 2023

H&S 1569.50 (a)(3) Conduct which is inimical to the health, morals, welfare or safety of either an individual in or receiving services from the facility or the people from the State of California. This regulation was not met as evidenced by: Based on Department investigation findings, it was determined that S1 engaged in sexual conduct with R1 constituting an act that is inimical to the health, safety and welfare of R1 receiving services from the facility. This violation poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2023

Plan of correction: Deficiency was CORRECTED. S1’s employment was immediately terminated on 9/18/22. Facility will conduct an in-service training to all the staff on the section cited and will provide LPA the proof of training conducted by 6/9/23.

Allegation investigated: Facility staff are not properly trained.

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver the findings for the complaint recieved on 2/17/23. LPA De Perio was greeted by West Division Operations Specialist who is also acting as Executive Director (ED) Lilit Mnatsakanyan and stated the purpose of the visit. For today's visit, there are a total of 80 residents in care of which 2 are on hospice. (SEE LIC9099-C) Unsubstantiated The Department has investigated the complaint alleging that facility staff are not properly trained. LPA conducted record reviews included but not limited to: the facility handbook, job descriptions (specifically for the receptionist and kitchen server) resident roster, staff roster (LIC500), staff trainings, front desk duties and front desk “template” which included “front desk FAQs” such as inquiries regarding: Bingo, move-ins, move-outs, emails and communication log, walkie-talkies, packages, emergency binders, maintenance work orders, human resources and payroll, laundry and trash, billing and invoices, pharmacy and doctors, sales and marketing. In addition, a concierge shift checklist is completed and provided, and a concierge shift log. LPA conducted a total of 10 interviews of which consisted of staff and residents, of which none of the interviews corroborated with the allegation. 10 out of the 10 interviews either stated that staff were “knowledgeable” and “well trained”, while the interviews conducted with staff verified that training is provided for all positions, and even if a staff member is asked to assist with a task other than their designated position, training is provided via “shadowing”. LPA reviewed the job descriptions for the receptionist and kitchen server positions and both positions had the same education and experience requirements, certification requirements, management, decision making, and knowledge and skills. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For today's visit, no citations were issued. An exit interview was conducted with ED Mnatsakanyan a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 16, 2023 · control 22-AS-20230217165102

Allegation investigated: Residents are not being accorded with dignity and respect.

Licensing Program Analyst (LPA) Celine De Perio made an unannounced complaint visit to the facility to initiate the 10-day visit for the complaint received on 2/21/23 and to deliver the findings. LPA De Perio was greeted by West Division Operations Specialist who is also acting as Executive Director (ED) Lilit Mnatsakanyan and stated the purpose of the visit. For today's visit, there are a total of 82 residents in care of which 3 are on hospice. LPA De Perio conducted interviews with staff and residents, and reviewed and requested copies of the pertinent records. This department has investigated the complaint alleging that residents are not being accorded with dignity and respect. Unsubstantiated LPA conducted a total of 10 interviews, which consisted of staff and residents. 10 out of the 10 interviews conducted did corroborate with the allegation. LPA conducted an interview with the facility resident council of which was reported that staff (S1) who is indicated in the allegation, is "great" and it was a "no brainer to nominate S1 as employee of the month", S1 is "efficient", "can do it all", and added that "sometimes these residents can have lots of demands, but she always keep her composure and is respectful and has never been anywhere near being disrespectful". LPA conducted an interview with the resident (R1) in the allegation who stated "every single worker here, I have no complaints about, and no issues". R1 also stated "the food and service is good, no bad attitudes, they are always friendly" LPA conducted an interview with S1 who stated "If I have things happening in my personal life, with stress and things that make me cry, I make sure I don't bring it here" S1 added "This is my dream job, I would not do anything to mess it up. I don't come from much, so having this job is everything to me" LPA reviewed the following documents but not limited to the: staff roster, resident roster, facility policies, dining and kitchen staff schedules, facility dining menu, dining and kitchen staff job description, roles and responsibilities, staff trainings, resident council notes, and physician report for R1. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. LPAs conducted an exit interview was ED Mnatsakanyan and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 3, 2023 · control 22-AS-20230221120641

Allegation investigated: Facility does not have adequate staffing to meet resident's needs. Staff does not provide adequate food service to residents in care. Facility does not have an administrator during operation hours. Facility is in disrepair.

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with Operations Specialist/Executive Director-Lilit Mnatsakanyan and stated the purpose of this visit, which was to deliver the final findings for the complaint received on 11/15/22 against this facility. For today's visit, there are a total of 84 residents in care of which 4 residents are on hospice. See LIC9099-C. Unsubstantiated This agency has investigated the allegation that the facility does not have adequate staffing to meet resident's needs. LPA De Perio conducted interviews and file reviews of which interviews conducted either stated that since the facility was turned over to new management, the facility now does have enough staff, or it was stated that the only area of the facility where there was not enough staff was in the dining room. LPA reviewed staff schedules and staff availability for both day and night shifts, and it was observed that facility did have sufficient amount of staff to assist with coverage and additional tasks. Based on observations, interviews and record reviews, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. This agency has investigated the allegation that staff does not provide adequate food service to residents in care. LPA De Perio conducted file reviews and interviews, and the interviews conducted stated that since the Dining Director at facility resigned, the dining area has been short-staffed. However, per record reviews and interviews, it was stated and observed that management has been working extra shifts in the dining area to ensure coverage. Based on the information gathered during the investigation and review of documents obtained, LPA observed that despite facility being short-staffed in the dining hall, facility did have an adequate amount of staff who assisted with coverage and tasks in the dining hall. LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. This agency has investigated the allegation that facility does not have an administrator during operating hours. The Reporting Party stated that the administrator that the allegation is referring to is the previous administrator and not the current administrator present in facility (as of September 2022 to January 2023). LPA De Perio interviewed a total of 7 individuals, of which 1 of the 7 declined wanting to be interviewed. Per the interviews conducted, it was stated that the previous administrator “didn’t do anything” “was never present” and “never showed her face”. Based on observations, interviews and record reviews, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. This agency has investigated the allegation that the facility is in disrepair. LPA De Perio was notified that upon facility elevator breaking, the facility contacted an elevator repair company in no more than 24 hours requesting for a repair. However, due to the elevator company being backlogged, the facility did not receive repair services right away. LPA De Perio also observed that the facility had an alternate elevator for individuals to utilize and that there was only 1 elevator in the entire facility that needed maintenance. Based on observations, interviews and record reviews, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For today’s visit, no deficiencies were issued and citations were issued per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Operations Specialist/Executive Director-Lilit Mnatsakanyan, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 23, 2023 · control 22-AS-20221115104657

Allegation investigated: Staff are not meeting resident's hygiene needs

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. Operations Specialist Lilit Mnatsakanyan arrived during the visit. During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as shower schedule and facility daily assignments. Regarding the allegation that staff are not meeting resident's hygiene needs, the investigation revealed the following: Per Resident 1's (R1) Personal Service Plan dated 03/01/2021, resident is scheduled for showers two times a week on Tuesdays and Saturdays. Review of shift reports dated 12/03/2021 and 12/08/2021 indicated R1 received 2 showers on a Wednesday and a Friday. Facility is unable to provide additional shift reports for December. Daily assignment sheets indicated resident was scheduled for showers but its unclear if the showers were provided. R1 indicates not receiving more than 1 shower a week and on occasion, no weekly shower. Staff interviewed indicated that R1 was a two person assist and if there was not additional staff, the resident would not be showered. Staff indicate short staffing during CONTINUED ON LIC 9099C DATED 01/19/2022 Substantiated this time frame and stated working alone on shift many times. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility along with appeal rights.the state’s words, verbatim · CDSS document, Jan 19, 2023 · control 22-AS-20211216143011

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jan 19, 2023

In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care.. that meet their individual needs and are delivered by staff that are sufficient.. This req is not being met as evidenced by: Based on interviews conducted, Licensee failed to ensure resident was receiving care in the way of showers. Resident was not receiving scheduled showers two times a week as personal service plan indicated. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 19, 2023

Plan of correction: Licensee to submit a detailed plan on how to ensure residents are receiving showers and hygiene care. Licensee to forward plan to LPA by POC due date.

Allegation investigated: Staff did not respond to resident's call for assistance in a timely manner

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. Operations Specialist Lilit Mnatsakanyan arrived during the visit. During the course of the investigation, LPA toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as pendant call log. Regarding the allegation that staff did not respond to resident's call for assistance in a timely manner, the investigation revealed the following: Staff interviewed indicate kitchen staff do not have pagers therefore would be unable to hear any pendant calls or pages regarding resident calls or needs. During the investigation, LPA reviewed pendant call logs from 12/03/2021-12/10/2021. LPA observed 102 staff responses were between 23-44 minutes. Administrator indicated expected response time was under 15 minutes and staff interviewed confirmed the time frame. LPA tested 5 pendants and received a staff response in two of the occasions. Three of the test pulls had no staff response. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, CONT ON LIC 9099C DATED 01/19/2022 Substantiated (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility along with appeal rights.the state’s words, verbatim · CDSS document, Jan 19, 2023 · control 22-AS-20211207162734

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 20, 2023

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not being met as evidenced by: Based on observation and record review, Licensee failed to ensure care and supervision was being provided to residents. 102 staff pendant responses were between 23-44 minutes as well as staff not responding to LPA's test pull. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 19, 2023

Plan of correction: Licensee to provide re-training to staff regarding staff response times and forward proof to LPA by POC due date.

Allegation investigated: Staff are not properly trained.

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility, reviewed staff training records and interviewed staff. Regarding the allegation that staff are not properly trained, the investigation revealed the following: Five out of five staff training records reviewed contained proof of current staff training. Training included but not limited to: Dementia training, Alzheimer's Disease, Postural Supports, Restricted Conditions and Personal Rights. Five out of five staff interviewed stated receiving training from the facility. Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility. Unfounded R2 is on a nectar thick diet which facility has documented resident refusal. During two different visits, LPA pulled the emergency cord in 5 rooms. LPA received four staff responses within 20 minutes and no response in one pull. Review of pendant pull/ emergency response times for 05/01/2022-05/08/2022 indicated 40 response times between 23 minutes and one hour. Administrator stated expected response times are within 15 minutes. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility along with appeal rights.the state’s words, verbatim · CDSS document, Jan 19, 2023 · control 22-AS-20220506152646

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 20, 2023

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not being met as evidenced by: Based on record review and observation, Licensee failed to ensure care and supervision was provided to residents. Emergency pendant response times ranged between 23 minutes and 1 hour for the week of 05/01/2022-05/08/2022 and LPA received no staff response in 1 out of 5 pulls. This poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Jan 19, 2023

Plan of correction: Licensee to provide a statement of understanding regrding the regulation and forward to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(2) · Plan of correction due date: Feb 2, 2023

Basic services shall at a minimum include: Safe and healthful living accommodations and services... This requirement is not being met as evidenced by: Based on record review and interviews, Licensee failed to ensure R1 was provided safe and healthful accommodations. Resident was served alcohol even though physician order indicates no alcohol for resident. This poses a potential health and safety risk to residents in care,the state’s words, verbatim · CDSS document, Jan 19, 2023

Plan of correction: Licensee to provide re-training to staff on following physician orders and forward proof to LPA by POC date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to conduct a case management: health and safety check in this facility. LPA De Perio met with West Division Operations Specialist/Acting Executive Director (ED) Lilit Mnatsakanyan and stated the purpose of this visit. LPA De Perio conducted a tour of the interior and exterior portions of the facility with ED Mnatsakanyan. The facility is a three level structure and is licensed for 155 non-ambulatory residents, of which 15 may be on hospice and 0 may be bedridden. Currently, there are a total census of 85 residents in care of which 4 are on hospice. LPA De Perio observed resident bedrooms to be in good repair, and is equipped with clean linens, adequate storage space, and kept free of tripping hazards. Water temperature in restrooms were measured to be at 113.6 degrees Fahrenheit. Smoke and carbon monoxide detectors were operational and most recent fire inspection took place on 11/12/2021, of which inspection was passed. Auditory alarms and wander guard functions were also tested and observed to be operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. LPA De Perio also tested pull cords in resident bathrooms and observed to be operational. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Facility had back-up emergency food and water supply. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and located in multiple areas of the facility. LPA De Perio observed exit stairwells and each floor had an evacuation chair. NOTE: facility does not have delayed egress doors. For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the main entrance behind the front desk. For this visit, LPA De Perio did not observe immediate threats on the health and safety of residents in care. No citation has been issued at this time. An exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 21, 2022

Allegation investigated: / Facility staff is under the influence when providing care to residents.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit to the facility for the purpose of investigating the allegation listed above. LPA was greeted and granted entry by Operations Specialist Lilit Mnatsakanyan and Executive Director Phat Nguyen after being screened and temperature checked for COVID-19. LPA listed the allegation being investigated. LPA requested and obtained select staff records, the current resident roster, the updated Personnel Report LIC500 as well as a copy of the Associate Handbook being provided to new employees upon hire. LPA additionally conducted interviews with Operations Specialist, Executive Director, Business Operations Manager, Health and Wellness Director, Programs Director, Programs Assistant along with one caregiver and two Med Tech staff members on duty on the day of the visit. Resident R1 was also interviewed during the visit. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 The majority of individuals intervieedw had either no knowledge or not directly witnessed any event or circumstances that would corroborate the allegation investigated. Documentation confirming a staff training session focused on the Associate Handbook and its clauses regarding Brookdale Irvine being a drug-free environment were provided to LPA during the visit. Management staff also indicates that random checks on the evening shift are conducted multiple times a week and have not provided any evidence of the alleged behavior happening at the facility. LPA was also able to tour the physical plant during the course of the complaint investigation. Based on records reviewed, observation made and interviews conducted, the allegation listed above is deemed 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 provided and a copy of this report was provided and left at facility.the state’s words, verbatim · CDSS document, Dec 1, 2022 · control 22-AS-20221129121238

Allegation investigated: Facility does not have sufficient amount of staff to meet resident's needs

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with Business Office Manager (BOM) Joshua Oliver and stated the purpose of this visit, which was to deliver the final findings for the complaint received on 8/23/22 against this facility. For today’s visit, there are a total of 91 residents in care of which 8 are on hospice. This agency has investigated the complaint alleging that facility does not have sufficient amount of staff to meet resident's needs. LPA De Perio conducted file reviews and interviews and obtained copies of pertinent documents. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. Unsubstantiated For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA De Perio conducted an exit interview with BOM Oliver, and a copy of this report was provided to the facility. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA De Perio conducted an exit interview with BOM Oliver, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 17, 2022 · control 22-AS-20220823163454

Allegation investigated: Staff is assisting residents while intoxicated

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with West Division Operations Specialist/Acting Executive Director (ED) Lilit Mnatsakanyan on behalf of AD Carrie Galloway and stated the purpose of this visit which was to deliver the final findings for the complaint received on 7/21/22 against this facility. This agency has investigated the complaint alleging that staff is assisting residents while intoxicated. LPA De Perio conducted file reviews, and interviews and 6 out of the 9 interviews conducted, verified that staff member was intoxicated. 1 out of the 9 interviews that was conducted was with the staff who claimed to be intoxicated, and per interview, staff stated “I went to dinner and do what adults do, then I went to work” but declined to provide further information. Per interview with AD Galloway on 7/26/22, it was also stated that staff had made previous reports about this individual and expressed concerns about intoxication. Per reporting party, AD Galloway stated “I already wrote her up”. Upon LPA De Perio requesting for a copy of the “write-up”, there were no records indicated nor found that one was ever created. Substantiated In the Brookdale Irvine Associate Handbook, section “Associate Responsibilities” on page 41, it states: “The list below, therefore, is not all encompassing; it is intended to provide examples of misconduct that are considered inappropriate and for which an associate may be terminated, even for a first offense...Reporting to work intoxicated or under the influence of alcohol or any drugs or controlled substances that may impact your ability to perform your job or otherwise pose safety concerns." On Page 57 titled “Drug-Free Workplace”, it states: “While on the job, no associate may use, possess, distribute, sell, or be under the influence of alcohol or illegal, non-prescribed, or over-the-counter drugs that may impact an associate’s ability to perform their job or otherwise pose safety concerns. Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. For today's visit citations were issued per Title 22 Division 6 of the California Code of Regulations. See LIC9099-D. LPA De Perio conducted an exit interview with AD Mnatsakanyan and a copy of this report, regulation discussed and specified on LIC9099-D and Appeal Rights were provided to the facility.the state’s words, verbatim · CDSS document, Oct 20, 2022 · control 22-AS-20220721144127

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a)(f) · Plan of correction due date: Oct 27, 2022

87411 Personnel Requirements - General (a) Facility personnel shall...be competent to provide the services necessary... (f) All personnel...shall be...physically and mentally capable... This requirement is not met as evidence by: Based on observation, interviews and record review, facility failed to ensure that personnel is competent to provide services necessary...and that personnel is physically and mentally capable of performing assigned tasks. This poses an immediate threat on the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 20, 2022

Plan of correction: As Plan of Correction (POC), administrator will provide training to staff about the regulation cited and will submit proof to assigned LPA and CCL on or by 10/27/22.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to conduct a case management and health and safety check in this facility. LPA De Perio met with West Division Operations Specialist/Acting Executive Director (ED) Lilit Mnatsakanyan and stated the purpose of this visit. LPA De Perio toured the interior and exterior portions of the facility with ED Mnatsakanyan. The facility is a three level structure and is licensed for 155 non-ambulatory residents, of which 15 may be on hospice and 0 may be bedridden. Currently, there are a total census of 94 residents in care. LPA De Perio observed resident bedrooms to be in good repair, and is equipped with clean linens, adequate storage space, and kept free of tripping hazards. Water temperature in restrooms were measured to be at 111.4 degrees Fahrenheit. Smoke and carbon monoxide detectors were operational and most recent fire inspection took place on 11/12/2021, of which inspection was passed. Auditory alarms and wander guard functions were also tested and observed to be operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. LPA De Perio also tested pull cords in resident bathrooms and observed to be operational. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Facility had back-up emergency food and water supply. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and located in multiple areas of the facility. LPA De Perio observed exit stairwells and each floor had an evacuation chair. Facility does not have delayed egress doors. For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the main entrance behind the front desk. LPA De Perio reminded ED Mnatsakanyan to ensure that Guardian roster is up to date and reflects current employees. For this visit, LPA De Perio did not observe immediate threats on the health and safety of residents in care. No citation has been issued at this time. An exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 4, 2022

Allegation investigated: Facility is not answering communications promptly to the resident's representatives. Facility is not providing resident's records to the resident's representatives.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Wellness Director (WD) Becky Kruse and explained the reason for today’s inspection. The investigation into the allegations that Facility is not answering communications promptly to the resident's representatives and Facility is not providing resident's records to the resident's representatives revealed the following: During the course of the investigation, LPA interviewed WD and Staff #1 (S1) and requested and reviewed the resident file for Resident #1 (R1). It was reported that a family member of R1 requested R1’s records from the facility, that the facility did not provide the records, and that after requesting additional documentation from the family member and not receiving it, the facility stopped responding to the family member. Unfounded LPA interviewed WD and S1 who stated that the facility’s privacy policy is to only release a resident’s records with a signed release. LPA reviewed the facility’s Notice of Privacy Practices, top of page 6, which states “Brookdale is required by law to maintain the privacy of Protected Health Information (“PHI”) and to provide you notice of our legal duties and privacy practices with respect to PHI.”. The Notice of Privacy Practices, bottom of page 6, identifies the following “uses and disclosures of PHI that do not require prior authorization”: “1. For Treatment,” “2. For Payment,” and “3. For Health Care Operations.” The Notice of Privacy Practices, middle of page 7, states that the facility “may also use and disclose your PHI without your prior authorization for these purpose”: “5. Disclosures to Family, Friends or Others Designated by You. We may disclose your PHI to a close friend, family member or other relative, or a person you designate, who is involved in your care or payment for your care, to the extent that the information is relevant to their involvement in your care. An example of this is if a family member transports and assists you with physician visits and staff gives them PHI necessary for a physician visit. If there is a person to whom you do not wish us to disclose the above information, please notify the Privacy Office. We may also use or disclose your PHI to notify (or assist in notifying) a family member, legally authorized representative or other person responsible for your care of your location, general condition or death.” WD and S1 stated that R1 had no POA or conservator. LPA’s review of R1’s file corroborated this statement and also revealed that R1 did not have a diagnosis of Dementia. LPA’s review of R1’s file revealed 2 other family members who signed various paperwork for R1 and were listed as contacts for the facility. However, the family member at issue was not listed as an emergency contact on R1’s Identification and Emergency Information (LIC601) and LPA did not see this individual’s name anywhere in R1’s file. Based on the evidence obtained, the facility was not required to provide the records requested or to continue communicating with this family member. The Department has investigated the above allegations and found them to be Unfounded, meaning the allegation were false, could not have happened, or are without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 26, 2022 · control 22-AS-20220819135812

Allegation investigated: Staff not properly trained on emergency procedures Not enough staff to ensure the safety of residents

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Wellness Director (WD) Becky Kruse and explained the reason for today’s inspection. The investigation into the allegations that staff are not properly trained on emergency procedures and there are not enough staff to ensure the safety of residents revealed the following: During the course of the investigation, LPA conducted on-site inspections on 08/27/21 and 10/19/21, inspected the facility, interviewed Administrator (AD) Carrie Galloway and residents, and obtained and reviewed copies of facility records. It was reported that, when the fire alarm went off on 08/21/21, there were not enough staff to direct residents and that the staff present were not properly trained on emergency procedures, which resulted in confusion during the alarm. AD stated that the fire alarm on 08/21/21 was a false alarm, the facility quickly determined it to be a false alarm, and so shortly after the alarm rang residents and staff were free to use the elevators. Unsubstantiated AD stated that, per the facility’s emergency procedures, when the fire alarm goes off, the fire doors close (but do not lock), residents are supposed to stay in in their rooms, and staff go section to section (going through the fire doors) checking on the residents or evacuating residents if necessary. Per AD, facility staff responded on 08/21/21 exactly how they were trained to respond. In terms of training, AD stated that residents are offered monthly training on fire safety, there is an annual evacuation drill, and staff are trained on fire precautions upon hire and yearly thereafter. LPA reviewed and confirmed the facility’s Fire and Emergency Evacuation Plan, Evacuation Plan, Facility Protocol for Evacuation, and Resident Emergency Guide which corroborate AD’s description of the fire protocols and document the fire protocols for staff and residents. LPA reviewed Direct Supply Tels Logbook Documentation showing that the facility regularly conducts fire drills. LPA reviewed facility training records which show all staff completed at least 2 fire training sessions in 2021. During LPA’s inspection on 08/27/21, LPA observed a spontaneous false fire alarm at the facility. During the alarm, LPA observed staff come to the front to receive instructions, the facility’s determination that the alarm was a false alarm, and staff proceeding to check on residents in an orderly manner. LPA interviewed 5 residents, 4 of whom corroborated AD’s statement that the facility’s fire protocol was properly followed on 08/21/21. LPA’s interview with AD and review of documents revealed that on 08/21/21, the facility had approximately 118 residents and had 5 caregivers, 1 office staff, 1 receptionist, and 6 kitchen staff, all of whom are trained on emergency procedures. During LPA’s inspections on 08/27/21 and 10/19/21, LPA did not observe a shortage of staff, and during the 08/27/21 inspection LPA observed staff checking on residents in an orderly manner. LPA interviewed 5 residents, none of whom stated the facility did not have enough staff to check on and direct residents during the 08/21/21 false alarm. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 26, 2022 · control 22-AS-20210823161046

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio was greeted by receptionist on duty who checked temperature prior to entering lobby waiting area. During the visit, LPA De Perio was accompanied by facility administrator (AD) Carrie Galloway. As of 8/8/22, there are no active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted throughout the facility. LPA observed the Administrator's Certificate for Carrie Galloway which expires on 10/28/2023. LPA De Perio toured the interior and exterior portions of the facility with AD Galloway. During this visit, there are a total of 24 staff members on duty. The facility is a three level structure and is licensed for 155 non-ambulatory residents, of which 15 may be on hospice and 0 may be bedridden. Currently, there are a total census of 100 residents in care. LPA De Perio initiated random bedroom checks, of which bedrooms were observed to have furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Water temperature in restrooms were measured to be at 113.4 degrees Fahrenheit. Smoke and carbon monoxide detectors were operational and most recent fire inspection took place on 11/12/2021, of which inspection was passed. Auditory alarms and wander guard functions were also tested and observed to be operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. LPA De Perio also tested pull cords in resident bathrooms, and observed to be operational. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Facility had back-up emergency food and water supply. LPA De Perio reviewed the most recent audit for the quarterly dietitian visit, which took place on 4/13/22. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and located in multiple areas of the facility. LPA De Perio observed exit stairwells and each floor had an evacuation chair. Facility does not have delayed egress doors. For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the main entrance behind the front desk. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the medication room, closet, and office. Medications were locked and inaccessible to residents in care. Toxins were also observed to be locked and inaccessible to residents. LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Galloway. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued. LPA De Perio advised AD Galloway to use the general email address: CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA. LPA De Perio conducted an exit interview with AD Galloway and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 8, 2022

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff are not allowing residents privately paid personal assistant to assist resident

Licensing Program Analyst (LPA) Kimberly Lyman conducted a 10 day complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility by Health and Wellness Director Becky Kruse and explained the reason for the visit. Carrie Galloway joined the visit in progress. During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegation that staff are not allowing resident's privately paid personal assistant to assist resident, the investigation revealed the following: Resident 1(R1) has a 24 hour care companion. Facility has notified responsible party that care companions are for companionship only and not for any caregiving duties. Facility staff are required to perform caregiving duties as part of basic services offered by the facility and department guidelines. Per Community Care Licensing regulation 87411, all facility staff performing assistance with activities of daily living shall receive initial and annual training. Care companions are not facility staff and not held to those requirements thus unable to provide assistance. CONTINUED ON LIC 9099C DATED 06/02/2022. Unfounded Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 2, 2022 · control 22-AS-20220527153953

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted a case management visit to follow up on an incident report submitted to Community Care Licensing on 05/25/2022. LPA was greeted and granted entry into the facility by Health and Wellness Director Becky Kruse and explained the reason for the visit. Carrie Galloway joined the visit in progress. Incident report dated 05/21/2022 indicated that Irvine PD had arrived at the facility to check on Resident 1 (R1). R1 had called the Veterans Administration (VA) Hospital who in turn called the authorities after the representative determined the resident may harm the resident. Irvine PD assessed the resident and determined the resident did not pose a risk of harm. Irvine PD left a report number, 22-05-8930, but declined to open a case. VA representative indicated resident had stated the resident would take all the resident's medications to harm the resident. Facility removed the resident's medications and put resident on two hour checks. R1 is currently on med management. During the visit, LPA met with R1. R1 indicated the situation was a misunderstanding and the resident had no intention of harm, just frustration with maneuvering the VA system. R1 stated no desire to harm oneself. Resident has had no incidents of suicidal ideation or self harming behavior. Physician report dated 04/15/2022 indicates R1 is mostly independent and at time of report was able to mange own medications. There is no diagnosis of Dementia or Mild Cognitive Impairment. No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 2, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports submitted to Community Care Licensing. LPA was greeted and granted entry into the facility by Executive Director Carrie Galloway and explained the reason for the visit. Incident report dated 03/03/2022 indicated Resident 1 (R1) was observed in the dining room choking by dietary staff. Facility LVN responded at 11:50 AM and immediately started the Heimlich Maneuver on resident. Staff called 911 at 11:53 AM while tending to resident. Staff moved the resident who was in a wheelchair to an adjacent room to continue the Heimlich Maneuver. Paramedics responded at 12:01 and immediately started life saving procedures. Resident was transported to Hoag Hospital at 12:12 PM where resident subsequently passed away on 03/10/2022. Per physician report dated 09/13/2021, R1 is able to self feed and is not on a special diet. Staff interviewed confirm while resident has left sided paralysis, the resident has no swallowing issues. There have been no other choking incidents with the resident. Incident report dated 03/06/2022 indicated facility received a phone call from Mason Regional Park Ranger stating R2 and R3 were lost at the park and R3 was in need of medical attention due to a fall at the park. Park ranger returned the residents to the facility and R3 was sent out for medical attention due to back pain. R3 returned the next day with no new orders. Mason Park is approximately one mile away. Per physician orders, both residents are unable to leave the facility unassisted. Facility investigation revealed residents may have left through a back door which had been propped open. Facility has a list of residents unable to leave the facility unassisted at the front desk. LPA observed front desk staff confirming residents can leave the facility while checking in. Facility has secured all doors except the front door to funnel everyone in and out of front door. Both residents have been fitted with wander guards and advised both are unable to leave facility. R3 previously had a wander guard but removed it. Facility is doing daily wander guard checks and documenting. LPA spoke with both residents during the visit and both appear safe and well taken care of. CONT ON LIC 809C DATED 03/16/2022. R2 is diagnosed with Mild Cognitive Impairment and R3 is diagnosed with Dementia. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 16, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on a death report submitted to Community Care Licensing on 02/24/2022. LPA was greeted and granted entry into the facility by Executive Director Carrie Galloway and explained the reason for the visit. Death report dated 02/23/2022 indicated Resident 1(R1) was found outside the resident's room around 1 AM on 02/22/2022 after pushing the pendant for assistance. R1 was confused and disoriented. R1 was assessed and had low oxygen saturation. R1 agreed for medical intervention and 911 was called. Paramedics responded and R1 became unresponsive on the stretcher. CPR was initially started but then stopped due to resident having a "Do not resuscitate" on file. Resident was pronounced dead at 2:19 AM. During the visit, LPA toured the facility and interviewed Executive Director as well as reviewed and obtained pertinent documentation such as physician report and facility notes. Per physician report dated 09/11/2019, R1 has a diagnosis of Type 2 Diabetes, Essential Hypertension, Hyperlipidemia, Unspecified Depressive Disorder, Benign Neoplasm of Prostate and Benign Prostatic Hyperplasia. Facility to provide a copy of death certificate to LPA upon receipt. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 25, 2022

Allegation investigated: Illegal Eviction

Licensing Program Analyst (LPA), Michelle Reed made an unannounced visit to the facility for the purpose of presenting the findings of the complaint investigation. Upon arrival, LPA met with Administrator Carrie Galloway. The investigation consisted of interviews with the facility staff, Administrator Carrie Galloway, and witnesses as well as documentation. The following was determined: Resident #1 (R1) was admitted into Brookdale Irvine on 11/24/20. At the time of admission R1 was bedridden and needed assistance with her ADL's. Staff were to use a hoyer lift to help transfer R1 due to lower extremity weakness. R1 did not want to use the hoyer lift for fear of falling and would often refuse physical therapy. R1 was a 2 person assist and then became a 3 person assist. On 10/14/21 R1's doctor provided notice in writing that R1 needed a higher level of care due to neuropathy. Brookdale issued a 30 day eviction notice on 10/20/21. Based upon Interviews and information obtained during the investigation the allegation is unfounded meaning the allegation was false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint and no deficiencies are being cited. The eviction is legal based upon R1 needing a higher level of care. An exit interview was conducted and copy of this report was provided to Administrator Galloway. Unfoundedthe state’s words, verbatim · CDSS document, Nov 19, 2021 · control 22-AS-20211103101156

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Administrator (AD) Carrie Galloway and discussed the purpose of the inspection. During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, and kitchen and observed the following: During the inspection, LPA and AD observed there were 30 staff present, wearing PPE. LPA observed 118 residents were present. LPA confirmed residents were doing well and observed no health and safety issues. LPA inspected common areas, resident rooms, and kitchen, and observed they were clean and organized, and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction. LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, communication and emergency plan, and dementia. LPA requested and reviewed resident roster, staff roster, staff files, resident files, emergency plan, and COVID-19 mitigation plan. There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Oct 19, 2021