Brookdale Sunwest

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to continue an annual inspection that was started on 11/25/2025. Upon arrival LPA was greeted by facility staff and granted entry. Employee records review began- Five (5) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current 07/01/2027. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 125.6 degrees F and caution warning labels observed. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the assigned area. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. Food Service- Food supply meets the of one week supply of nonperishable and 2-day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. (Continued on Page 2) (Continued from Page 1) LPA made observations throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation, and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational; contracted company also conducted fire sprinklers quarterly and last done on 11/16/2025 and alarms are serviced yearly and last done on 3/11/2025. Fire extinguishers are tested annually and were last done on 11/07/2025. The facility conducting emergency disaster drills monthly and last done on 11/5/2025. Corporation is active and in good standing. Based on the information received during this visit today, zero deficiency is being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with Theresa Ward and a copy provided at the time of the exit interview.the state’s words, verbatim · CDSS document, Dec 2, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry by Juanita Jackson. LPA began inspection with introduction, visit purpose and provided the facility Health & Wellness Director with LPA identification and business card. Theresa Ward arrived during the inspection. Resident record review began- Five (5) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Due to time constraints, Annual will need to be completed at a different day. Based on the information received during this visit today, there are no deficiency is being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with Theresa Ward and a copy provided to the facility representative at the time of the exit interview.the state’s words, verbatim · CDSS document, Nov 25, 2025

Allegation investigated: Inadequate staffing resulting in residents falling while in care.

Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegation. LPA met with Juanita Jackson and explained the reason for the visit. The investigation consisted of the following: On 12/15/21 LPA Cuevas conducted an unannounced initial visit. On 12/21/21 LPA Cuevas conducted a subsequent visit and conducted a tour of the facility. On 11/7/25 LPA Flores contacted administrator and requested staff schedule for December 2021 and current, resident and staff roster. On 11/17/25 LPA Flores interview 1 staff. On 11/19/25 LPA Flores conducted interviews with 5 residents and 3 staff. The investigation revealed the following: Regarding allegation: Inadequate staffing resulting in residents falling while in care. It is alleged there is one staff caring for 20 residents. (CONTINUED ON LIC 9099C) Unsubstantiated Interview with administrator revealed there are 4 caregivers during the day, and afternoon shifts along with additional staffing. There are 2 caregivers and a medication technician during the night shift. Per administrator during 2021 they did have some staff issues, but they had kept the same number of staff as today to cover the shifts. There was a time when the facility had 13 residents, and they had less staff. Interviews with residents revealed there is always staff available to assist in each shift. Interviews with staff corroborated the administrator’s staff numbers per shift and stated there are no residents that require additional care. LPA reviewed incident reports and noted that between September -November 2025 two falls have been reported to the department and between October-December of 2021 there were 4 falls reported to the department. Although residents may have fallen there is not enough evidence to say there was not enough staffing during December of 2021 or currently to provide care and supervision. 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 Juanita Jackson and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 18-AS-20211210110500

Allegation investigated: Facility does not have adequate staff to meet resident's needs.

On August 06, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the unannounced facility and met with Licensee. LPA explained the reason for the visit was to provide findings for the complaint investigation. On October 15, 2024, Community Care Licensing received a complaint alleging, facility does not have adequate staff to meet resident’s needs. During the investigation, LPA conducted interviews, record reviews, and made observations pertaining to the listed allegation. Regarding the allegation facility does not have adequate staff to meet resident’s needs, it was reported that when residents are calling for staff through the signal system, residents are required to wait for more than 30 minutes due to a lack of available staff. When interviewed, Administrator, Theresa Ward denied the allegation. Unsubstantiated Administrator stated the management team has hired new team members, including care and personnel staff. It was advised that all new hires are available for assistance on the floor as needed. Interview with Executive Director, Juanita Jackson disputed the allegation indicating there were no residents at the time of the complaint requiring a two person assist on either side of the facilities programs. Executive Director stated there are always sufficient staff scheduled for each shift. Interview with additional staff stated the facility utilizes the "Service Alignment" Program, which is a system which determines how many staff are needed pertaining to the residents that the facility has in care. Interviews with additional staff stated there are no concerns regarding sufficient staff. Staff also stated there were no concerns addressed by residents regarding wait times. Information obtained from interviews with residents stated there are no concerns or issues with staff responding to the call pendants or how many staff are available to assist. Interviews with additional residents indicated staff are present and available to assist with needs. LPA’s review of the records determined the program does indicate how many staff are needed per shift. LPA also reviewed “Labor Detail Report”, “Service Alignment Benchmark”, and the “Staff Sign-In Sheets” which revealed there were enough staff to provide adequate care and supervision to the residents in care on all scheduled shifts. Information obtained from additional witnesses indicated the Med-techs are extra back, the cooks, housekeeping team and the activities coordinator will each step in to assist if there is an issue or any concerns. Based on interviews, record review, and observations, the allegation that facility does not have adequate staff to meet the resident’s needs has been deemed unsubstantiated. An allegation determined unsubstantiated means although the allegation may have occurred there is not sufficient evidence to support the listed allegation. An exit interview was conducted. A copy of this report was explained and given to Licensee, Shemika Johnson.the state’s words, verbatim · CDSS document, Aug 6, 2025 · control 18-AS-20241015170006

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with Associate Executive Director Juanita Jackson who was informed of the purpose of the visit. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards and LPA observed the facility courtyard with outdoor furniture and shaded area for residents. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies, detergents, and the sharp and dangerous objects were locked and inaccessible to the residents in care. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector, carbon monoxide, and facility sprinkler system was operational and is maintained annually with the last inspection dated 03/29/2024. Facility kitchen had the ability to prepare food in clean environment. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA was informed the facility receives multiple food deliveries a week. LPA observed medication room in Assisted Living was locked and the medication cart lock to be locked and inaccessible to residents in care. MedTechs document medication administration on the facility's electronic Medication Administration Record (eMAR). LPA reviewed four staff files and training. All staff have the required personnel records on file and criminal record clearance, health screening report, and updated training along with CPR/First Aid Certification. Five (5) resident files were reviewed, and possessed all required paperwork which included their Identification Sheet, Consent Forms, Needs and Service Plan, and updated Physician's Report. Facility has an updated emergency and disaster plan and Infection Control plan. LPA observed all facility exits were clear from obstructions. Facility contained multiple charged fire extinguishers located throughout the facility with an inspection date 11/07/2024. Facility conducts disaster/fire drills with the last drill conducted in 10/2024 which met Department Requirements. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Associate Executive Director Jackson.the state’s words, verbatim · CDSS document, Nov 26, 2024

Type of visit: Required - 1 Year

On 11/9/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA met with Executive Director, Theresa Ward, Associate Executive Director, Juanita Jackson and Health & Wellness Director, Parminder Singh who were informed of the purpose of visit. LPA toured the Assisted Living and Memory Care Unit with Juanita Jackson. The following was observed, reviewed, and inspected: The physical plant, in general, was in good repair. The facility is operating in the capacity approved by Community Care Licensing (CCL). The buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. LPA inspected a sample of resident bedrooms and bathrooms in the Assisted Living & Memory Care Unit. Resident bedrooms have the required bedding and furniture; such as clean mattresses, night stands, storage space, and sufficient lighting. Room temperatures were comfortable for residents in care. LPA inspected a sample of resident bathrooms; the bathroom appliances were operating in safe and sanitary conditions. LPA measured the hot water temperature in the sampled bathrooms, in which all bathroom sinks measured within regulation. Sampled bathrooms were equipped with non-skid surfaces and grab bars. Bedrooms were equipped with a pull cord system to notify staff of any emergencies. LPA toured the kitchen and dining area. The facility was stocked with a 2-day supply of perishable and 7-day supply of non-perishable food items that were labeled appropriately. The facility had a menu posted and available for review. Dishes, glasses, and utensils were in good condition and stored in a healthful manner. LPA inspected the common areas. Smoke detector were tested and functioning properly. LPA observed several carbon monoxide alarms throughout the facility. Continue on LIC809-C Continued from LIC809 There was a locked and centralized storage area for medications, including refrigerated medications. Medications appeared to be dispensed and documented appropriately. The facility had a designated area for resident files and staff files. All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Random staff and residents' records were reviewed. All required postings, including COVID’s postings, were posted near the entryway and throughout the facility. There was adequate seating in the common areas and several activity rooms. LPA observed several activity posters. The facility was also equipped with a complete first aid kit as well as the first aid manual. LPA inspected the outdoor area of the facility. There was shaded area with seating. Overall, the facility was clean, in good repair, and operating in safe conditions for residents in care. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was reviewed and provided to Theresa Ward.the state’s words, verbatim · CDSS document, Nov 9, 2023