306000831-4-23-2024-22-AS-LMOA-D4TR6B-20240430124428

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000831
Report Date: 04/23/2024
Date Signed: 04/23/2024 11:03:07 AM

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 Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240417114300

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: 92	DATE:	04/23/2024
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Jeri Miles- Executive Director		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility is not adhering to resident's Admission Agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Jessica Cho and Edward Kim arrived at the facility unannounced to initiate the 10-day complaint investigation into the above allegation. LPAs stated the purpose of the visit to Business Office Manager (BOM) Patricia Jimenez, and Executive Director (ED) Jeri Miles was also adivsed of the visit upon arrival. During the course of the investigation, LPAs interviewed staff and obtained copies of pertinent documentation for Resident #1 (R1) which includes: Resident Roster, Personnel Report, Face Sheet, Physician's Report, Residency Agreement, Physician Certification Letter, March/April 2024 Rent Receipts, Visitor Sign-In/Out Sheets, and Notes. The following was determined:

It is alleged that the facility is not adhering to the resident's admission agreement. Based on the review of the staff's notes, R1 was admitted to the hospital on March 27, 2024 and has not returned to the facility since. Two out of the two staff interviews revealed that R1's Responsble Person (RP) moved out R1's personal belongings on April 1, 2024, providing a certification letter to the facility written by a social worker dated April 1, 2024, and communicating their intent to move out R1.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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-20240417114300

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: 04/23/2024

NARRATIVE

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Per review of the Residency Agreement docusigned and dated on April 12, 2023 by both parties, the agreement states on page 8, Section D, that the agreement will be immediately terminated "upon written notice if a physician certifies... in writing" due to reasons of health. As a result of the agreement, facility requested that the RP obtains a physician certified letter in lieu of a letter certified by a social worker. The physician certified letter dated April 16, 2024 was provided to the facility which is the effective date of R1's move. It is determined based on the evidence obtained that the facility is not adhering to the resident's admission agreement due to not issuing a prorated refund.

Therefore, based on LPAs' interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. A deficiency is being cited on the attached LIC 9099D.

An exit interview was conducted with Executive Director Jeri Miles, and a copy of this report including the LIC9099C, LIC9099D, LIC811, and the appeal rights were provided at the end of the visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240417114300

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: 04/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/30/2024 Section Cited CCR 87507(f)	1 2 3 4 5 6 7	87507 Admission Agreement (f) "The licensee shall comply with all applicable terms and conditions set forth in the admission agreement..." This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Executive Director stated they will issue a refund to R1's responsbile party, and to submit an Acknowledgement of Understanding for the said deficiency to LPA via email by POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review, facility did not adhere to the admission agreement pertaining to refunds which poses a potential Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC9099 (FAS) - (06/04)

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