BROOKDALE IRVINE

Official classification

Type B

Official code

1569.657(a)

Regulation authority

HSC

What the official deficiency says

Rate increase due to change in level of resident care; notice ... (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. This requirement is not met as evidenced by: Responsible party of R1 stated they did not receive notice or signed or agreed with Personal Service Plan updates. No sign copy of Personal Service Plan for disputed charges on April 14, 2023 service plan updates.

Official plan of correction

Management staff will provided written statement of understanding for regulation that was cited and emailed to LPA. And will conduct an inservice training on admission agreements and provide proof to LPA by POC due date.

Deadline recorded: Dec 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The Licensee did not comply with the section cited above due to 4 out of 4 staff stating the facility is understaffed. This poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

Based on the staff roster reviewed on 11/8/2024, LPA determined that, since June 2024, the facility has hired: 2 Cooks, 8 Servers and 2 Dishwashers. LPA determined facility fulfilled the POC. POC cleared during visit

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed that five of five staff records reviewed did not have a Health Screening Report.

Official plan of correction

POC Due Date: 09/27/2024 Plan of Correction Licensee to completed a Health Screening Report (LIC503) for five staff and email proof to LPA by POC due date.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA did not observe a complaint poster in areas accesible to residents.

Official plan of correction

POC Due Date: 09/20/2024 Plan of Correction Licensee to post Complaint Poster and email proof to LPA by POC due date.

Official classification

Type B

Official code

87205(a)

Regulation authority

CCR

What the official deficiency says

87205 Accountability of Licensee Governing Body (a) The licensee, whether an individual or other entity, shall exercise general supervision...and the welfare of the individuals it serves. This requirement is not met as evidence by: Based on the Department’s interviews conducted, during the duration of S1’s employment, despite the complaints of inappropriate behaviors and intoxication, knowing about the sexual harassment allegations, the former management failed to exercise general supervision over the affairs of the licensed facility, initiate any forms of disciplinary action, and allowed for S1 to continue working at the facility. This poses a potential health and safety risk to residents in care.

Official plan of correction

As a plan of correction (POC) ED will provide understanding of the regulation cited, and will formulate a training to all staff on the importance of not coming to work intoxicated. ED will provide proof to assigned LPA on or by May 30, 2024.

Deadline recorded: May 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. This requirement is not met as evidence by: Based on the Department’s interviews conducted, during the duration of S1’s employment, S1 was reported of coming into work intoxicated, and facility failed to ensure S1 was physically and mentally capable of providing care to residents. This poses a potential health and safety risk to residents in care.

Official plan of correction

As a plan of correction (POC), S1 was terminated on September 17, 2023. Deficiency cleared.

Deadline recorded: May 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator… This requirement is not met as evidence by: Based on the Department’s interviews conducted, during the duration of S1’s employment, despite the complaints of inappropriate behaviors and intoxication, management failed to initiate any forms of disciplinary action. Facility failed to perform the duties of a qualified administrator. This poses a potential health and safety risk to residents in care

Official plan of correction

As a plan of correction (POC) facility has hired a new administrator Deficiency cleared

Deadline recorded: May 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure 2 out of 3 residents received assistance with medications when the facility ran out of supply, which poses an immediate health risk to persons in care.

Official plan of correction

The licensee stated they will create a plan to ensure that medication supply does not run out and submit the plan to LPA by POC due date and will train all medication technicians on the plan and submit proof to LPA within 7 days.

Deadline recorded: Oct 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure sufficient staffing when residents had to wait up to 1 hour and 15 minutes for assistance after calling, which poses a potential health risk to persons in care.

Official plan of correction

The licensee stated they will review call wait time records, create a plan to ensure wait times are not excessive during busy periods, and submit the plan to LPA by POC due date.

Deadline recorded: Oct 23, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

8775(c)

Regulation authority

CCR

What the official deficiency says

87755 Inspection Authority of the Licensing Agency (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours... This requirement is not met as evidence by: Based on record reviews and interviews, licensee did not comply with the regulation cited and did not provide CCL staff with the requested documents. This poses a potential health and safety risk to residents in care.

Official plan of correction

Facility is to review the regulation cited and provide proof of understanding to LPA on or by 08/16/2023.

Deadline recorded: Aug 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Based on the reviewed documents obtained and interviews conducted during the investigation, facility did not obtain timely medical care for seriously injured resident. This poses an immediate health and safety risk for residents in care.

Official plan of correction

As a plan of correction (POC), facility is to conduct an in-service training to all staff regarding the regulation cited.

Deadline recorded: Aug 4, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs…the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidence by: Based on the reviewed documents obtained and interviews conducted during the investigation, facility failed to ensure that the resident was regularly checked. This poses an immediate health and safety risk for residents in care.

Official plan of correction

As a plan of correction (POC), facility is to conduct a training with all staff regarding the regulation cited and will implement and document resident health and safety checks on a daily basis.

Deadline recorded: Aug 4, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.50(a)(3)

Regulation authority

HSC

What the official deficiency says

H & S 1569.50 (a)(3) Conduct which is inimical to the health, morals, welfare or safety of either an individual in or receiving services from the facility or the people from the State of California. This regulation was not met as evidenced by: Based on Department investigation findings, it was determined that S1 engaged in sexual conduct with R1 constituting an act that is inimical to the health, safety and welfare of R1 receiving services from the facility. This violation poses an immediate safety risk to residents in care.

Official plan of correction

Deficiency was CORRECTED. S1’s employment was immediately terminated on 9/18/22. Facility will conduct an in-service training to all the staff on the section cited and will provide LPA the proof of training conducted by 6/9/23.

Deadline recorded: Jun 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care.. that meet their individual needs and are delivered by staff that are sufficient.. This req is not being met as evidenced by: Based on interviews conducted, Licensee failed to ensure resident was receiving care in the way of showers. Resident was not receiving scheduled showers two times a week as personal service plan indicated. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to submit a detailed plan on how to ensure residents are receiving showers and hygiene care. Licensee to forward plan to LPA by POC due date.

Deadline recorded: Jan 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not being met as evidenced by: Based on observation and record review, Licensee failed to ensure care and supervision was being provided to residents. 102 staff pendant responses were between 23-44 minutes as well as staff not responding to LPA's test pull. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to provide re-training to staff regarding staff response times and forward proof to LPA by POC due date.

Deadline recorded: Jan 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not being met as evidenced by: Based on record review and observation, Licensee failed to ensure care and supervision was provided to residents. Emergency pendant response times ranged between 23 minutes and 1 hour for the week of 05/01/2022-05/08/2022 and LPA received no staff response in 1 out of 5 pulls. This poses an immediate health and safety risk.

Official plan of correction

Licensee to provide a statement of understanding regrding the regulation and forward to LPA by POC due date.

Deadline recorded: Jan 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(2)

Regulation authority

CCR

What the official deficiency says

Basic services shall at a minimum include: Safe and healthful living accommodations and services... This requirement is not being met as evidenced by: Based on record review and interviews, Licensee failed to ensure R1 was provided safe and healthful accommodations. Resident was served alcohol even though physician order indicates no alcohol for resident. This poses a potential health and safety risk to residents in care,

Official plan of correction

Licensee to provide re-training to staff on following physician orders and forward proof to LPA by POC date.

Deadline recorded: Feb 2, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)(f)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a) Facility personnel shall...be competent to provide the services necessary... (f) All personnel...shall be...physically and mentally capable... This requirement is not met as evidence by: Based on observation, interviews and record review, facility failed to ensure that personnel is competent to provide services necessary...and that personnel is physically and mentally capable of performing assigned tasks. This poses an immediate threat on the health and safety of residents in care.

Official plan of correction

As Plan of Correction (POC), administrator will provide training to staff about the regulation cited and will submit proof to assigned LPA and CCL on or by 10/27/22.

Deadline recorded: Oct 27, 2022. A deadline is not proof that correction was completed.