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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881034
Report Date: 09/28/2023
Date Signed: 10/16/2023 02:37:38 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/22/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230922140927
FACILITY NAME:BROOKDALE LOMA LINDAFACILITY NUMBER:
361881034
ADMINISTRATOR:LUJAN, MARITZAFACILITY TYPE:
740
ADDRESS:25585 VAN LEUVEN STREETTELEPHONE:
(909) 796-5421
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:220CENSUS: 102DATE:
09/28/2023
UNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Maritza Lujan, Executive DirectorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
The facility carpet is not clean.
Staff yelled at resident.
Staff disclosed a resident's medical diagnosis to the residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to initiate an investigation and deliver the finding on the above allegations. LPA met with Executive Director Maritza Lujan and explained the purpose of the visit. The investigation included file reviews, facility tour, and interviews with relevant parties.

Allegation #1 "The facility carpet is not clean". The allegation alleged that stains/spots were observed on the carpet in a resident’s room. The allegation alleged that a request was made to have the carpet cleaned but it did not happen. LPA Nickolas' interview with the executive director revealed that they denied this allegation. LPA Nickolas' interview with staff #1 (S1) revealed that they denied this allegation. LPA Nickolas’ interview with R1 revealed that they confirmed this allegation. LPA Nickolas' interview with staff # 2 (S2) and staff #3 (S3) also denied this allegation. LPA Nickolas' file review revealed that two (2) requests for carpet cleaning were submitted to clean the carpet in R1's room, and the facility fulfilled those requests. LPA Nickolas observed several carpet stains in R1’s room.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20230922140927
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: BROOKDALE LOMA LINDA
FACILITY NUMBER: 361881034
VISIT DATE: 09/28/2023
NARRATIVE
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 However, LPA Nickolas’ interview with the executive director confirmed that the carpet stains in R1's room are consistent with the assisted devices used by R1, and R1 is currently on the waiting list for a studio without carpet. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.
Allegation #2 “Staff yelled at resident”. The allegation alleged that S1 yelled and degraded R1. LPA Nickolas’ interview with the executive director revealed that they denied this allegation. LPA Nickolas’ interview with S1 revealed that they denied this allegation. LPA Nickolas’ interview with R1 revealed that S1 yelled at them. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #3 “Staff disclosed a resident's medical diagnosis to the residents in care”. The allegation was that R1's medical diagnosis was being revealed to the residents in care by the facility's staff. LPA Nickolas' interview with the executive director revealed that they denied this allegation. LPA Nickolas' interview with staff #4 (S4) revealed that they denied this allegation. LPA Nickolas' interview with R1 revealed that they overheard a former employee reveal their medical diagnosis to resident #2 (R2). LPA Nickolas' interview with R2 revealed that they denied this allegation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and copy of this report was provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2