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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881034
Report Date: 02/15/2024
Date Signed: 02/15/2024 05:01:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/30/2021 and conducted by Evaluator Yolanda Delgado
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210730133208
FACILITY NAME:BROOKDALE LOMA LINDAFACILITY NUMBER:
361881034
ADMINISTRATOR:ADAMS, LUCINDAFACILITY TYPE:
740
ADDRESS:25585 VAN LEUVEN STREETTELEPHONE:
(909) 796-5421
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:220CENSUS: 107DATE:
02/15/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:MaritzaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff did not dispense resident's medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Yolanda Delgado made an unannounced visit to the facility to deliver findings for a complaint investigation into the allegation listed above. During the investigation, LPA interviewed four (4) staff members and eight (8) residents. LPA reviewed pertinent documents pertaining to the allegation. LPA was unable to interview pertinent residents due to refusal.
On July 30, 2021, Community Care Licensing received a complaint indicating that facility staff did not dispense resident’s medication as prescribed. It was reported facility staff stopped giving Resident #1 (R1) medication for an unspecified amount of days until the facility received R1’s new prescription. It was also reported that R1 had a current prescription that they were not distributing to R1.

Additional witness visited the facility on May 21, 2022
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
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 3
Control Number 18-AS-20210730133208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: BROOKDALE LOMA LINDA
FACILITY NUMBER: 361881034
VISIT DATE: 02/15/2024
NARRATIVE
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(continued from page 1)
On May 30, 2022, it was also alleged that Resident #2 (R2) was given last antidepressant medication on May 20, 2022. Information from additional witness reported that refill medication was provided to the facility on May 5, 2022, but the medication was unable to be located.
Information obtained from staff interviews stated that facility staff has always provided medication as prescribed. It was advised that Med Techs are responsible to distribute the medication to residents. It was also advised that the facility utilizes a program to document the distribution of medication and med techs are responsible to document the medication. Information obtained from additional witness stated that they visited the facility on May 21, 2022 and the facility was still not able to locate R2’s medication. Additional witness stated that they distributed R2’s medication due to having spare medication on their person. Additional witness stated she planned to provide medication to R2 on May 22, 202, but facility staff contacted additional witness and advised that the medication was located. Information obtained from record review of R1 Medication Administration Record, (MAR) revealed that R1 did not received prescribed medication on the following dates: 7/23/2021, 7/25/2021, and 7/26/2021. It was also observed that R2 did not receive prescribed medications on 5/21/2022.
Based on interviews and observation, the allegation that the facility did not dispense resident medications as prescribed is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The facility will be cited for violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Sections 87465(c)(2). This poses a health and safety risk to clients in care.

An exit interview was conducted with Maritza Lujan. A copy of the report, 9099-D, along with Appeal Rights were provided to Maritza Lujan.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210730133208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BROOKDALE LOMA LINDA
FACILITY NUMBER: 361881034
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2024
Section Cited
CCR
87465(c)(2
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87465 Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need...but can communicate his/her symptoms clearly, facility staff
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Administrator stated the facility has implemented medication refill log for the past 1 year, nurses conduct quality assurance audits, Omnicare provides pharmacy audit and provides to facility quarterly.
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designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3