306000831-2-5-2025-22-AS-SSAS-DE4VJ9-20250221152823

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000831
Report Date: 02/05/2025
Date Signed: 02/05/2025 04:17:53 PM

Unsubstantiated

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
11/12/2024 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20241112102106

FACILITY NAME:	BROOKDALE GARDEN GROVE		FACILITY NUMBER:	306000831
ADMINISTRATOR:	JERI MILES		FACILITY TYPE:	740
ADDRESS:	10200 CHAPMAN AVE		TELEPHONE:	(714) 636-6453
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92840
CAPACITY:	140	CENSUS: 103	DATE:	02/05/2025
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Jeri Miles, Executive DIrector		TIME COMPLETED:	04:32 PM

ALLEGATION(S):

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Staff do not ensure the facility is free from mold

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegation listed above. LPA was greeted and granted entry by facility administrator Jeri Miles after stating the purpose of the visit and listing the allegation investigated.

An initial complaint investigation was conducted on November 18, 2024. During the visit, LPA accompanied by facility maintenance director Francisco Sarabia conducted a tour of the physical plant's both levels, including the main lobby, staff break room, laundry room, water heater closet, water softener room, television room and library, dwelling unit wings, hallways and staircases on both the ground level and upper level. Three occupied units were inspected during the visit on both levels. The facility's central courtyard and rose garden were also visited. The memory care was also inspected including the common area and four shared units and the secure courtyard.
CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20241112102106

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: 02/05/2025

NARRATIVE

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CONTINUED FROM FORM LIC9099
During the present visit, LPA requested the facility census and toured the premises again. A total of six resident interviews were conducted during the visit.

Regarding the allegation that Staff do not ensure the facility is free from mold, the following has been concluded: Based on two tours of the physical plant, a review of a total seven units during the initial inspection and seven units on the present visit as well as interviews with six residents, LPA was able to corroborate the occurrence of a water damage incident in the facility's boiler room in November 2024. Adequate containment measures were observed and the room was observed to be dry upon a second visit. Regarding leaks along sprinklers or air conditioners, no instances of leaks or indications of the potential presence of mold were evidenced. Interviews conducted additionally failed to provide sufficient evidence of suspicion of mold on the premises either.

As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

LIC9099 (FAS) - (06/04)

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