306000831-12-22-2021-22-AS-AORZ-CB9PEZ-20220202101556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000831
Report Date: 12/22/2021
Date Signed: 12/22/2021 02:26:30 PM

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
12/06/2021 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20211206105331

FACILITY NAME:	BROOKDALE GARDEN GROVE		FACILITY NUMBER:	306000831
ADMINISTRATOR:	PAMELA BRADLEY		FACILITY TYPE:	740
ADDRESS:	10200 CHAPMAN AVE		TELEPHONE:	(714) 636-6453
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92840
CAPACITY:	140	CENSUS: 82	DATE:	12/22/2021
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Michael Sokolowski		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility failed to provide refund

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unnanounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility by Executive Director Michael Sokolowski and explained the reason for the visit.

During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as billing record and admission agreement. Regarding the allegation that facility failed to provide refund, the investigation revealed the following: Responsible party signed admission agreement on 06/24/2021. On 07/02/2021, responsible party notified facility that Resident 1 (R1) would not be admitting into the facility due to R1's physician not providing a Dementia diagnosis. Facility requested responsible party to pay $5120 for monthly rent which responsible party did. Community Care Licensing regulations provide for a refund of pre-admission fees. In this case, facility discounted pre-admission fees and requested payment of monthly rent only. Facility admission agreement requires a thirty day notice for a refund. Therefore, the allegation is deemed CONTINUED ON LIC 9099C DATED 12/22/2021

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

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-20211206105331

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: 12/22/2021

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC9099 (FAS) - (06/04)

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