Brookdale Murrieta

Allegation investigated: Staff are not providing assistance making medical appointments

On June 26, 2026, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced at the facility and met with the Receptionist, Alyssa Valerio. LPA explained that the visit was conducted to deliver findings for the listed allegation. During the investigation, LPA conducted interviews, record reviews, and made observations. On June 17, 2026, Community Care Licensing received a complaint alleging staff are not providing assistance making medical appointments. It was reported that Resident 1 (R1) needed to see a specialist due to a reoccurring issue and that the facility had not assisted R1 with scheduling necessary medical appointments. Information obtained from interviews with Administrator and facility staff advised that R1 does not reside at the listed facility. . Information obtained from Additional Witness confirmed that R1 does not resident at the facility. A review of facility records and Resident Rosters corroborated the information obtained from interviews. Based on interviews, record reviews, and observation, it has been determined the allegation has been made against the incorrect facility. Therefore, this investigation has been deemed unfounded, meaning the allegation is false, did not happen, and could not have occurred. The department has dismissed the complaint. An exit interview was conducted and a copy of this report was provided to the Receptionist, Alyssia Valerio. Unfoundedthe state’s words, verbatim · CDSS document, Jun 26, 2026 · control 18-AS-20260617161016

Type of visit: Required - 1 Year

On 06/01/2026, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Health and Wellness Director (HWD) Kelly Best who was informed of the purpose of the visit. The facility has a fire clearance to serve 82 non-ambulatory elderly residents of which 10 may be bedridden. LPA toured the facility with HWD Best and was informed the facility is designated for independent and assisted living only. Indoor and outdoor passageways are free of obstruction. LPA observed fire alarm systems, carbon monoxide detectors and fire extinguishers throughout the facility. LPA also observed the facility has two decorative water fountains which LPA determined they are not considered a large body of water such as a swimming pool, hot tub, wading pool, or fishpond. LPA toured the kitchen and observed the facility met Departmental requirements for a two-day supply of perishable foods and seven-day supply of non-perishable food items. The culinary director reported that kitchen staff accommodate resident's dietary needs. LPA toured a model resident room which had the required bedding, furniture and lighting, and the bathroom had grab bars in the shower. Medications are secured in medication carts, only accessible to authorized personnel such as wellness nurses or medication technicians. The facility has several activity rooms and outings available for resident leisure. No immediate health or safety concerns were observed during today's visit and no deficiencies were cited. An exit interview was conducted and a copy of this report was reviewed and provided to HWD Best.the state’s words, verbatim · CDSS document, Jun 1, 2026

Allegation investigated: Staff did not prevent a resident from inappropriately touching another resident in care.

On 3/3/2026, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose launching the complaint investigation into the allegation listed above. LPA met with Executive Director Cindy Garcia and explained the purpose of the visit. Information received alleged staff did not prevent Resident #2 (R2) from inappropriately touching Resident #1 (R1). Interviews conducted with facility staff report that R1 had a history of making false allegations against other residents in care. Staff reported that on 10/25/2025, R1 alleged an unknown staff member enter into R1’s room and sexually assaulted R1. It was reported that Executive Director (ED) contacted the local police department, and an investigation was conducted pertaining to the incident. Interviews with staff and R1’s responsible person reported that R1 had a surveillance camera in R1’s room which was monitored by R1’s responsible person. (Continue to LIC9099C) Unsubstantiated (Continuation from LIC9099) The camera was implemented in the room as R1 had a history of making allegations of other residents entering into R1’s room and stealing R1’s items. During that time when the camera was implemented in the room, R1 made their first allegation of an unknown staff entering into their room and sexually assaulting R1. The surveillance footage was provided to local law enforcement and reviewed by R1’s responsible person. The footage was reviewed and the information provided by R1 could not be corroborated. A medical assessment was conducted for R1 following the incident where R1 was diagnosed with a Urinary Tract Infection (UTI). Interview with R1’s responsible person reported that they believed R1 to be experiencing delusions from the diagnosed UTI. R1’s responsible person further reported that the camera was removed as the camera was experiencing technical difficulties. The camera was no longer in R1’s room during the second incident of the sexual assault allegations. R1’s responsible person believed that the camera spiked R1’s paranoia causing R1’s to make frequent allegations of residents enter into R1’s room and/or stealing R1’s items. R1’s responsible person reports receiving a call from ED early February of 2026, informing them of an additional sexual assault allegation by R1. R1’s responsible person does not believe the allegation to be true as R1 was unable to make consistent statements, often changing the date and time of the incident. Following the incident, R1 tested positive for another UTI. Interviews with R1’s responsible person believed the allegation was a result of possible delusions. Interviews with staff report R1 had a fixation on R2 as R1 alleged that R2 was the person who was entering R1’s room and stealing R1’s items. LPA was unable to interview R1 as LPA learned of R1’s passing during the initial visit. Interview with R2 declined any claims of sexual abuse. R2 reports that R1 professed their love to R2. R2 reported declining R1's advances. R2 further reports that after R2 declined R1 advances, R1 began making false claims against R2 alleging that R2 was entering into R1's room and stealing R1's items. LPA attempted to speak with Resident #3 (R3) who shares a common wall with R1. Interview attempt with R3 was unsuccessful as R3 was unavailable. Due to insufficient evidence the allegation of staff did not prevent a resident from inappropriately touching another resident in care is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means although the allegation may have happened and/or is valid, there is not a preponderance of evidence to prove the allegation did or did not occur. An exit interview was conducted, and a copy of this report was provided to Executive Director Cindy Garcia.the state’s words, verbatim · CDSS document, Mar 3, 2026 · control 18-AS-20260223172841

Allegation investigated: Staff handled resident in a rough manner. Staff not meeting resident toileting needs. Staff did not provide medical attention to resident in care.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit. LPA met with Celia Saldivar and explained the reason for the visit. The investigation consisted of the following: On 7/5/23 LPA Mixson conducted an unannounced initial complaint investigation visit, interviewed 4 residents and 5 staff, and requested pertaining documents. On 10/27/25 LPA Flores contacted administrator and requested copies of physician’s report, service plan, admission agreement, medication list, notes, incident reports for resident #1(R1). On 10/29/25 LPA Flores conducted interviews over the phone with 5 staff. On 10/30/25 LPA conducted interviews with 3 residents over the phone. On 11/3/25 LPA Flores interviewed 3 additional residents and conducted a tour of the facility during another complaint investigation. On 11/4/25 LPA delivered findings for the above allegations. (CONTINUED ON LIC 9099C) Unsubstantiated The investigation revealed the following: Regarding allegation: Staff handled resident in a rough manner. It is alleged resident was thrown by facility staff out of the facility. Interviews with residents revealed 6 out of 6 residents stated staff treat them with respect, have not hurt them, or yell at them. 1 out of the 6 stated there is a staff that is rude but has not verbally or physically assaulted residents. LPA was unable to interview R1, as R1 is no longer at the facility. Interviews with staff revealed there have not been observations or reports of staff mistreating residents. Per administrator there are no warnings or other documents provided to staff to warrant staff mistreated residents within the last 2 years. Facility staff received personal rights training between 4/17/23 – 4/21/23 and most recently on 9/25/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff not meeting resident toileting needs. It is alleged resident had dry feces and was unkept. Interviews with residents revealed 3 out of 6 residents stated staff assist with changing as needed and are prompt. 3 out of 6 residents do not require assistance with incontinence care. Therefore, they didn’t have an answer regarding this question. But they stated they have not observed residents with odors due to incontinence. LPA was unable to interview R1 as R1 is no longer at the facility. Interviews with staff revealed residents are assisted with toileting as needed. Residents with incontinence care are provided assistance every two to four hours depending on their needs. If a resident requires assistance more often staff provide it as needed. Per staff if a resident is in isolation the care continues to be provided as needed while taking proper infection control precautions. Per administrator, on 6/28/23 R1 was found on the floor and had recently had a bowel movement. Per their facility protocol if the resident is in the floor and cannot be move emergency services are called. In this case R1 could not have been changed before going to the hospital as facility’s protocol is not to move the residents until emergency services arrived. In this case R1. LPA was unable to interview R1, as R1 is no longer at the facility. Documents review revealed incident report dated 6/29/23 notes R1 had a fall on 6/28/23 in which emergency services were called. Although the allegation could have happened, per administrator R1 required emergency services at that time. Due to the circumstances, facility staff was unable to provide toileting care during the incident. The allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. (CONTINUED ON LIC 9099C) Regarding allegation: Staff did not provide medical attention to resident in care. It is alleged R1 had skin tears and an eye infection. Interviews with residents revealed 6 out of 6 residents stated that if they needed medical assistance, they would notify Med-tech and they will obtain medical assistance for them. Interviews with staff revealed upon a change in condition or need to send a resident out, the Med-tech and facility’s nurse evaluate the situation and send the resident out to the hospital. Unless the resident refuses, then responsible parties are contact. Documents review revealed per physician’s report dated: 5/17/23 R1 had a medical condition in the right eye. Per Order summary report on 6/20/23 R1 was prescribed treatment for eye condition. Physician’s fax report dated: 6/24/23 notes R1 had a fall and sustain a skin tear which was treated by staff and physician was notified. Although R1 was observed with skin tears and an eye infection per facility records, R1 received treatment for both. Therefore the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Kelly Best Health and Wellness Director an a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 4, 2025 · control 18-AS-20230629115702

Allegation investigated: Staff did not ensure that resident was bathed Staff did not provide adequate housekeeping services to resident Staff did not provide resident transportation to medical appointments

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint visit regarding the above allegations. LPA met with Cindy Garcia and explained the reason of the visit. The investigation consisted of the following: On 12/1/23 LPA Shaw Ross conducted an initial complaint investigation visit, interviewed 4 staff, 1 resident, and requested the pertaining documents. On 10/27/25 LPA Flores contacted administrator and requested copies of physician’s report, service plan, admission agreement, notes, incident reports for resident #1(R1). On 10/29/25 LPA Flores conducted interviews over the phone with 5 staff. On 10/30/25 LPA Flores interviewed 3 residents over the phone. On 11/3/25 LPA Flores conducted a facility tour and observed 6 randomly chosen resident bedrooms, interviewed 3 additional residents and delivered findings for the above allegations. The investigation revealed the following: Regarding allegation: Staff did not ensure that resident was bathed. It is alleged resident’s baths have been missed and not done as scheduled. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with residents revealed 5 out of 6 residents stated to obtain assistance with showers/bathing as schedule or as needed. 1 out of 6 residents does not need assistance at this time. Interviews with staff revealed residents’ basic services for showers/baths are two showers per week. Unless the resident or responsible party requires more per week, which is discuss and an additional fee is charged. Per staff R1 used to refuse showers/bed baths if a specific staff member was not available or if the staff were late to the scheduled shower. However, the facility staff assisted and encouraged showers. Administrator stated they would ensure the staff was available and that staff showed up at the scheduled time. R1 no longer resides at the facility. Therefore, R1 was not interviewed. Interview with responsible party noted baths were scheduled twice a week. Documents reviewed revealed R1’s admission agreement dated: 8/27/21 notes R1 would receive basic services. Service plan dated 11/1/23 notes R1 was scheduled to receive bed baths twice a week. Although, facility staff may have missed scheduled baths, there are no records that indicate R1 was not assisted with showers for an extended period of time. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not provide adequate housekeeping services to resident. It is alleged resident’s trash bin and bed is not being done daily. Interviews with residents revealed 3 out of 6 residents stated facility staff assist to make their bed daily and take out trash once a week or as needed during their housekeeping day. 2 out of 6 residents stated they make their own bed, but housekeeping cleans their room once a week. 1 out of 6 residents stated there have been times when housekeeping has forgotten to do the resident’s bed and they had to do it on those days. Interviews with staff revealed caregivers are in charge of making the residents’ beds and removing the trash from the residents’ rooms daily. Housekeepers are to clean the apartments once a week, which includes changing the linens. LPA was unable to interview R1, as R1 no longer resides at the facility. On 10/30/25 R1’s responsible party stated that staff was not making the bed at least once per week for an extensive period of time. During facility’s tour conducted on 11/3/25 LPA Flores observed all residents’ beds made and no trash in the residents’ trash cans. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.(CONT. LIC 9099C) Regarding allegation: Staff did not provide resident transportation to medical appointments. It is alleged facility cannot accommodate transportation to resident’s medical appointments. Interviews with residents revealed 3 out of 6 residents stated to receive assistance with transportation to medical appointments and to not have concerns with facility only scheduling two days out of the week. 3 out of 6 residents either didn’t have a comment about transportation services or did not needed assistance with transportation at this time, therefore, not receive it. Interviews with staff revealed facility’s transportation services for medical appointments are scheduled two days out of the week. If a resident needs assistance on a different day facility staff assist by scheduling other transportation means. Documents reviewed revealed Admission agreement dated: 8/27/21 notes they will provide transportation services to resident #1. Addendum to the Basic Services dated: 8/27/21 guides residents to read the resident handbook for transportation services. LPA reviewed the resident’s handbook and did not find additional information. However, welcome package has listed transportation, "Drop off and Pick up only...Monday & Tuesday Medical appointments." Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Cindy Garcia and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 3, 2025 · control 18-AS-20231128085956

Type of visit: Required - 1 Year

Licensing Program Manager (LPM), Tricia Danielson and Licensing Program Analyst (LPA) Stephanie Martinez, conducted an unannounced visit to the facility for a required annual inspection. The LPM and LPA were allowed entrance into the facility and met with Executive Director (ED), Cindy Garcia. The LPA informed the ED of the purpose for their visit. The inspection included the following: Physical Plant: LPA Martinez inspected several resident rooms and required furniture was observed to be available. There are no bodies of water located on the property. According to the ED, no weapons are stored on the property. The facility is being maintained at a comfortable temperature. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid material available. The facility was kept clean and free of any odors. The hot water was tested and found to be within regulatory standards. An inspection of the fire systems was completed by the fire department on 02/02/2024 Food Service: There is a minimum of 2 days supply of perishable foods and 1 week's supply of non-perishable foods available. Sufficient supplies were available for resident's dinning use. Dinning room was observed to be clean. Record Review: All staff were observed to have appropriate fingerprint clearances. LPA did not observe any excluded individuals on the premises at time of visit. There is a disaster and mass casualty plan in place. All services requiring specialized skill are being performed by an appropriately skilled professional. Resident's files were reviewed and were observed to have required documentation. The facility has active liability insurance. Medication Review: The LPA inspected the medication room and observed resident's medications to be secured and well organized. Staff and Resident Interviews: Interviews were completed with several staff and residents. Staff interviews revealed sufficient competency. Resident interviews revealed sufficient care is being provided. No concerns were observed during interviews. An exit interview was conducted; this report was reviewed with ED Garcia and a copy was provided. No citations have been issued at this time.the state’s words, verbatim · CDSS document, Jun 25, 2024

Allegation investigated: Staff are overcharging resident in care. Staff do not provide resident with an itemized list of charges.

Licensing Program Analyst (LPA), Jacqueline Shaw Ross made an unannounced visit to deliver findings for the allegations noted above. LPA met with Celia Saldivar, Business Office Coordinator and explained the purpose of the visit and the elements of the allegations. The investigation consisted of observations, interviews, and records review. On 08/02/2023, Community Care Licensing received an allegation that staff are overcharging resident in care and staff do not provide resident with an itemized list of charges. R1 and his wife (R2) share a unit at the facility together. It was alleged that R1 noticed what appeared to be a double charge on their bank statement of Personal Service charges for May 2023. Per interview with R1, stated they did not understand the charges and expressed that staff in the facility seemed unwilling to explain charges to him. LPA interviewed both R1 and R2, as well as reviewed their bank statement. Cont'd on LIC9099C.... Unfounded Cont'd from LIC 9099.... LPA then interviewed Business Office Manager who informed LPA that R1 previously inquired on May 19, 2023, about an itemized list of charges and again last week. Business Office Manager states she discussed requested information directly to R1 on 05/19/23. Business Office Manager states she offered R1 documents detailing the Personal Service charges for the months in question, but R1 declined. During the complaint investigation visit, LPA witnessed a verbal exchange between R1 and Business Office Manager, in which R1 was provided a copy of R1's Personal Rate Increase account statement for the months of March 2023 thru May 2023. R1 indicated that he now understood the charges and that there was no discrepancy. R1 also indicated he did recall a conversation with the Business Office Manager in May 2023 in which she explained the charges and offered a printout of the charges to R1, but he declined a printout at that time. LPA requested and received pertinent documents that included a copies of R1 and R2's Admission Service Agreement, Physician's Report, Account History reports, and an itemized list of the last six months' Account History report of Personal Services charges for review. Business Office Manager contacted Corporate office Accounts Receivable to clarify the charges and provided a printout to LPA. LPA reviewed all documents. Documents received from Business Office Manager, did not show an increase in Personal Service Rates during the time period indicated by R1. Based on observation, interviews, and records review, the allegation of staff are overcharging resident in care and staff do not provide resident with an itemized list of charges, is UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted where a copy of this report was reviewed and provided to Celia Saldivar, Business Office Manager.the state’s words, verbatim · CDSS document, Dec 1, 2023 · control 18-AS-20230802133907