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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000831
Report Date: 11/25/2024
Date Signed: 11/25/2024 03:32:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2024 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240417072007
FACILITY NAME:BROOKDALE GARDEN GROVEFACILITY NUMBER:
306000831
ADMINISTRATOR:JERI MILESFACILITY TYPE:
740
ADDRESS:10200 CHAPMAN AVETELEPHONE:
(714) 636-6453
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY:140CENSUS: 94DATE:
11/25/2024
UNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Jeri Miles-AdministratorTIME COMPLETED:
03:46 PM
ALLEGATION(S):
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Facility did not provide all requested records to authorized representative
Facility did not allow resident to participate in care planning
Facility did not allow resident to choose healthcare provider
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on April 17, 2024. LPA was greeted and granted entry into the facility and met with Administrator (AD) Jeri Miles. LPA explained the reason for the visit.

This Department has investigated the complaint alleging that facility did not provide all requested records to authorized representative. Resident 1 (R1) was admitted to the facility on September 22, 2023. Documents reviewed included the Physician Report (LIC602) dated February 12, 2024 for R1. Per Physician report R1’s diagnoses are Hypertension and Major Depressive Disorder. During the investigation LPA reviewed documents including the Progress Notes dated September 22, 2023 through March 01, 2024. During the visit on November 25, 2024 LPA reviewed additional Progress notes dated March 01, 2024 through April 03, 2024. R1 was discharged from the facility on April 03, 2024.

CONTINUED ON LIC9099-C...


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
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 4
Control Number 22-AS-20240417072007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BROOKDALE GARDEN GROVE
FACILITY NUMBER: 306000831
VISIT DATE: 11/25/2024
NARRATIVE
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Per Witness 1 (W1) as of November 25, 2024 they have not received R1's records for March 2024.

Regarding the allegation that facility did not allow resident to participate in care planning, the following was revealed: During the course of the complaint LPA reviewed documents including the Senior Doc New Provider orders dated February 10, 2024 for R1. Per Provider orders it states patient may remain in the community in a locked/secured area/unit. During the course of the interviews, W1 reported that she is the Authorized Representative for R1. W1 stated that on February 10, 2024 she was not notified regarding the updated care planning. Per W1 the Health and Wellness Director notified a family member but not the Authorized Representative.

Regarding the allegation that facility did not allow resident to choose healthcare provider, the following was revealed: During the investigation LPA reviewed documents including the Personal Service Plan dated February 12, 2024 for R1. Per Personal Service Plan under comments it states Resident with Scan as of move in. Per Progress notes on February 10, 2024 R1 had a tele medicine visit with a provider from Senior Doc. LPA reviewed the Scan monthly visit dated February 12, 2024 for R1. Per Scan notes patient was seen and evaluated inside the Memory Care.

Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: facility did not provide all requested records to authorized representative, facility did not allow resident to participate in care planning and facility did not allow resident to choose healthcare provider are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

An exit interview was conducted with AD Miles and a copy of this report along with the Appeal Rights were provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20240417072007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BROOKDALE GARDEN GROVE
FACILITY NUMBER: 306000831
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2024
Section Cited
CCR
87506(c)(1)
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(c)All information and records obtained from or regarding residents shall be confidential. (1)...The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.
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Licensee to provide R1's records to their Authorized Representative. Licensee to email POC to LPA by POC due date.
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This requirement was not met as evidence by: the facility did not provide R1's records for March 2024. This poses a potential risk to persons in care.
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Type B
11/29/2024
Section Cited
CCR
87467(3)
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Resident Participation in Decisionmaking (3)The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident’s condition,
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Licensee to read and sign a statement of understanding. Licensee to email a copy to LPA by POC due date.
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or once every 12 months, whichever occurs first. This requirement was not met as evidence by the facility not arranging a meeting with R1 and their Authorized Representative prior to placing R1 in Memory Care. This poses a potential risk to persons 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.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20240417072007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BROOKDALE GARDEN GROVE
FACILITY NUMBER: 306000831
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2024
Section Cited
CCR
87468.2(a)(7)
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Additional Personal Rights of Residents in Privately Operated Facilities (a)(7) To fully participate in planning their care, including the right to attend and participate in meetings or communications regarding care and services to be provided, according to
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Licensee to read and sign a statement of understanding. Licensee to email a copy to LPA by POC due date.
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Health and Safety Code section 1569.80 and involve persons of their choice in this planning. This requirement was not met as evidence by: On 02/10/24 R1 had a tele medicine visit by a Provider from Senior Doc.; however, R1's provider was from Scan Health Plan. This poses a potential risk to persons 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.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4