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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000831
Report Date: 03/03/2025
Date Signed: 03/03/2025 04:08:31 PM

Document Has Been Signed on 03/03/2025 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BROOKDALE GARDEN GROVEFACILITY NUMBER:
306000831
ADMINISTRATOR/
DIRECTOR:		JERI MILESFACILITY TYPE:
740
ADDRESS:10200 CHAPMAN AVETELEPHONE:
(714) 636-6453
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 140TOTAL ENROLLED CHILDREN: 0CENSUS: 115DATE:
03/03/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Jeri MilesTIME VISIT/
INSPECTION COMPLETED:
04:22 PM
NARRATIVE
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This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20250205085503. LPA met with Administrator (AD) Jeri Miles and explained the reason for today’s inspection.

During the course of the investigation, LPA inspected the facility, conducted health and safety checks on residents, interviewed AD, and obtained and reviewed copies of the resident roster, staff roster, and Resident #1’s (R1) Progress Notes.

LPA reviewed R1’s Progress Notes which state that: on February 1, 2025, R1 had an unwitnessed fall, sustained a laceration to their head, was treated at a hospital, and returned to the facility the same day; on February 4, 2025, R1 had an unwitnessed fall, sustained a bruise to their head, was treated at a hospital, and returned to the facility the same day; and on February 5, 2025, R1 had an unwitnessed fall, did not sustain any injuries, and was seen by a nurse at the facility. However, based on incident reports received at the Orange County Regional Office (OCRO) and AD’s admission, R1’s fall on February 1, 2025, was not reported as required.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
Armando J LuceroTELEPHONE: (714) 703-2840
Sean HaddadTELEPHONE: (714) 335-7094
DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/03/2025 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: BROOKDALE GARDEN GROVE
FACILITY NUMBER: 306000831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2025
Section Cited
CCR
87211(a)(1)(B)

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87211 Reporting Requirements (a) … (1) A written report shall be submitted to the licensing agency … within seven days of the occurrence of … (B) Any serious injury… This requirement was not met as evidenced by:
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Licensee stated that they will retrain staff on reporting requirements and submit proof to LPA by POC due date.
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Based on documents and admission, the licensee did not ensure R1’s fall on February 1, 2025, was reported to licensing, which poses a potential safety 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.
Armando J LuceroTELEPHONE: (714) 703-2840
Sean HaddadTELEPHONE: (714) 335-7094

DATE: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025

LIC809 (FAS) - (06/04)
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