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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000831
Report Date: 03/24/2025
Date Signed: 03/24/2025 04:30:18 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/05/2025 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250205085503
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: 112DATE:
03/24/2025
UNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Brisseth ArrellanoTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Resident sustained a head injury due to lack of supervision
Resident sustained multiple falls due to lack of supervision
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Brisseth Arrellano, discussed the purpose of the inspection, and explained the allegations.

The investigation into the allegations that resident sustained a head injury due to lack of supervision and resident sustained multiple falls due to lack of supervision revealed the following: During the course of the investigation, LPA inspected the facility, conducted health and safety checks on residents, interviewed Administrator (AD) Jeri Miles, residents, staff, and witnesses, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Progress Notes, R1’s Physician’s Report dated November 29, 2023, R1’s Personal Service Plan dated January 1, 2024, R1’s Personal Service Plan dated August 30, 2024, R1’s Personal Service Plan dated January 1, 2024, R1’s Personal Service Plan dated September 18, 2024, Staff Training Records, R1’s Medical Records dated February 4, 2025, and the facility’s staff schedule.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
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 3
Control Number 22-AS-20250205085503
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 03/24/2025
NARRATIVE
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It was alleged that, due to lack of care and supervision, R1 had multiple falls at the facility that resulted in a head injury. LPA inspected the facility, conducted health and safety checks on R1 and other residents, and did not observe any health and safety issues. 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. LPA interviewed AD and one facility staff who reported that R1 moved in on December 9, 2023, was not a fall risk when they moved in, and had the facility’s basic fall prevention plan which includes encouraging residents to engage in the common area so they can be more closely monitored by staff and regular checks when they are in their rooms. LPA reviewed R1’s Physician’s Report dated November 29, 2023, which indicates R1 has Dementia, does not have any impairments relating to movement, is ambulatory, and can independently transfer to and from bed. Per R1’s Progress Notes, R1 had multiple falls in 2024. When interviewed, AD and facility staff stated that none of R1’s multiple falls in 2024 resulted in fractures or hospitalization, the facility reassessed R1 and noticed that R1’s balance issues were worsening, the facility held multiple care plan meetings with R1’s responsible party and updated R1’s care plan multiple times to address R1’s changing needs, and the facility conducted staff trainings on safe resident transfers, ergonomics, and gait belts. LPA reviewed R1’s Personal Service Plan dated January 1, 2024, R1’s Personal Service Plan dated August 30, 2024, and R1’s Personal Service Plan dated September 18, 2024, which corroborate that services were added to R1’s care plan as R1’s balance declined to ensure the facility was meeting R1’s needs with regards to their increasing fall risk. LPA also reviewed Staff Training Records that corroborated that the facility conducted additional staff training relating to falls. Per R1’s Progress Notes and interview with AD, R1’s falls in February 2025 did not result in hospitalization or fractures and R1’s laceration and bruise healed quickly with no issues. LPA reviewed R1’s Medical Records dated February 4, 2025, which indicate that R1 did not sustain any serious head injury from their fall on February 4, 2025. AD stated that in response to R1’s falls in February 2025, the facility took additional measures to address R1’s fall risk, including adding a fall mat, a wheelchair, and medication changes as facility staff had suspected one of R1’s medications was contributing to R1’s balance issues. Per AD and R1’s Progress Notes, R1 has not had a fall since February 5, 2025. LPA reviewed the facility’s staff schedule and did not note any staffing issues that may have contributed to R1’s falls. LPA interviewed R1’s responsible party who had no concerns about the care R1 was receiving at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250205085503
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 03/24/2025
NARRATIVE
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LPA interviewed two care staff and did not obtain information corroborating the allegations. LPA interviewed 12 residents and did not obtain information corroborating the allegations. Based on the information obtained, while R1 has sustained falls at the facility, the falls did not result in serious injury or hospitalization and the facility has diligently updated R1’s care plan to address R1’s changing needs.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3