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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361881034
Report Date: 11/26/2024
Date Signed: 11/26/2024 04:31:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/21/2024 and conducted by Evaluator Sarina Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241121111551
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: 112DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director Maritza LujanTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff handled resident in a rough manner
Staff not treating resident with respect
Staff left resident unattended for multiple hours
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPA met with Executive Director Maritza Lujan, and discussed the purpose of the visit.

Regarding allegation #1, LPA conducted 3 staff interviews, 3 out of the 3 staff informed LPA S#1 had handled R#1 in a rough manner. Executive Director followed the proper reporting requirements notified CCLD and the local Police Department, S#1 has been placed on suspension since 11/16/24 pending an internal investigation.

LPA conducted 5 resident interviews, 1 out of the 5 residents informed LPA S#1 handled resident in a rough manner, 4 out of 5 residents informed LPA staff does not handle them in a rough manner.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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 56-AS-20241121111551
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BROOKDALE LOMA LINDA
FACILITY NUMBER: 361881034
VISIT DATE: 11/26/2024
NARRATIVE
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Regarding allegation #2, LPA conducted 3 staff interviews, 3 out of the 3 staff informed LPA they treat residents with respect; however S#1 did not treat R#1 with respect.

LPA conducted 5 resident interviews, 1 out of the 5 residents informed LPA S#1 was always rude to them however, all other staff treat them with respect. 4 out of the 5 residents informed LPA staff treat them with respect.

Regarding allegation #3, LPA conducted 3 staff interviews, 3 out of the 3 staff informed LPA they do not leave residents unattended however, 2 out of the 3 staff informed LPA S#1 had left R#1 and R#2 unattended for a long period of time.

LPA conducted 5 resident interviews, 2 out of the 5 residents informed LPA they have been left alone for a long period of time by S#1 however, no other staff have left them unattended. 3 out of the 5 residents stated they are independent but have never been left unattended when help was needed.

Based on the evidence gathered during the investigation, the above allegations are Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Personal Rights 87468.1 (a) from division 6, chapter 8, article 8 is being cited on the attached LIC 9099 D.



An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights and LIC 9099D to Executive Director Maritza Lujan.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 56-AS-20241121111551
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROOKDALE LOMA LINDA
FACILITY NUMBER: 361881034
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2024
Section Cited
HSC
87468.1(a)
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87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity...(2)To be accorded safe...(3)To be free from punishment... This requirement is not met as evidence by:
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Administrator has agreed to review Personal Rights Regulation Provide training to all staff support .Licensee will ensure that training is signed and dated by all support staff and email proof to LPA by POC date.
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Based on interviews, the Administrator did not ensure Personal Rights to be met for residents, which poses an immediate Health, Safety, or Personal Rights risk for people in care.
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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: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3