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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000831
Report Date: 06/21/2024
Date Signed: 06/21/2024 03:01:56 PM

Document Has Been Signed on 06/21/2024 03:01 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: 89DATE:
06/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Jeri Miles, Administrator and Brisseth Rivera, Health and Welllness DirectorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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 On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz conducted a subsequent visit to cite deficiency discovered during the investigation of Complaint Control #22-AS-20240226102932. LPA met with Jeri Miles, Administrator and Brisseth Rivera, Health and Wellness Director and discussed the purpose of the visit.

During the course of the investigation, based on interviews and file review, the facility did not provide 30 day written notice to Resident 1 (R1) and their responsible party prior to moving R1 from Assisted Living to Memory Care unit. This poses a potential risk to residents in care.

An exit interview was conducted with AD Jeri Miles, and a copy of this report LIC 809 D, Appeal Rights and LIC 811- Confidential Names list were provided at exit.

Alisa OrtizTELEPHONE: (714) 703-2855
Rosie QuirozTELEPHONE: (559) 753-4610
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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 06/21/2024 03:01 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: 06/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
06/25/2024
Section Cited
CCR
87468.2(a)(16)

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87468.2(a)(16):Additional Personal Rights of Residents in Privately Operated Facilities (a)... residents...shall have...:(16) To written notice of any room changes at least 30 days in advance unless...agreed to...to fill a vacant bed, or...due to an emergency. This requirement was not met as evidenced by:
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AD stated the facility will submit a statement of understanding of the regulation cited and will provide in service training to all staff and provide proof to CCL by POC due date of 1/25/2024.
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The licensee failed to ensure this additional personal right was afforded to R1. Based on interviews and file review, the facility did not provide written notice to R1’s responsible party within 30 days of moving R1 to memory care unit. This poses a potential risk to residents 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.
Alisa OrtizTELEPHONE: (714) 703-2855
Rosie QuirozTELEPHONE: (559) 753-4610

DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024

LIC809 (FAS) - (06/04)
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