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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000831
Report Date: 12/30/2025
Date Signed: 12/30/2025 04:45:23 PM

Substantiated


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
07/26/2021 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210726164318
FACILITY NAME:BROOKDALE GARDEN GROVEFACILITY NUMBER:
306000831
ADMINISTRATOR:PAMELA BRADLEYFACILITY TYPE:
740
ADDRESS:10200 CHAPMAN AVETELEPHONE:
(714) 636-6453
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY:140CENSUS: 114DATE:
12/30/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ted DawitTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff was rough with resident resulting in injury
Failure to report
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 staff Ted Dawit and explained the reason for today’s inspection.

The investigation into the allegations that staff was rough with resident resulting in injury and of failure to report revealed the following: During the course of the investigation, LPA inspected the facility, interviewed staff and residents, and obtained and reviewed copies of the resident roster, staff roster, an incident report dated July 27, 2021, the facility’s investigation, Staff #1’s (S1) staff file, Staff #2’s (S2) staff file, and the facility’s report of suspected dependent adult/elder abuse dated July 26, 2021.

CONTINUED
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
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 4
Control Number 22-AS-20210726164318
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2025
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities (a) … (3) To be free from punishment, humiliation, intimidation, abuse… This requirement was not met as evidenced by:
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The licensee has already investigated the situation and terminated the staff involved. Licensee stated they will submit their training records on resident refusals and resident rights to LPA by POC due date.
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Based on observation and interviews, the licensee did not ensure R1 was free from abuse when S1 and S2 forced care on R1 resulting in bruises, which poses an immediate personal rights risk to persons in care. CIVIL PENALTY ASSESSED.
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Type B
01/27/2026
Section Cited
CCR
87211(a)(1)(D)
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87211 .. (a) … (1) A written report shall be submitted to … the person responsible for the resident within seven days of... (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse …This requirement was not met as evidenced by:
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The licensee stated they will review section 87211 and submit a plan to ensure incidents are properly reported to LPA by POC due date.
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Based on documents and interviews, the licensee did not ensure R1’s responsible party received a written notification of R1’s rough handling by staff resulting in bruises, which poses a potential personal rights 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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20210726164318
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: 12/30/2025
NARRATIVE
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Regarding the allegation that staff was rough with resident resulting in injury: it was alleged that Resident #1 (R1), a memory care resident, was handled roughly by staff resulting in bruises. LPA interviewed the facility’s wellness director who stated that R1 was a new resident and on July 22, 2021, S1 witnessed S2 trying to change R1, R1 kept refusing, and S2 forcefully grabbed R1 and changed them, but S1 did not report this incident and it was only discovered the next morning at which point a full investigation was conducted resulting in S1 and S2 being terminated.

LPA reviewed an incident report dated July 27, 2021, which states that on July 22, 2021, at approximately 9:20PM, R1 was changed in a manner which caused bruising to their right forearm, R1 reported this incident on July 23, 2021, S1 and S2 were suspended pending investigation, and local law enforcement, the Long Term Care Ombudsman, and R1’s family were notified of the incident on July 26, 2021. The facility’s wellness director stated that there had been no prior incidents with S1 or S2 and after the incident was discovered, all other residents were checked and no similar injuries were discovered. Per the facility’s wellness director, the facility’s protocol for care refusal is to make multiple attempts, to notify management so other staff can make attempts, and if that does not work to reach out to the family and doctor to explore other options. The facility’s wellness director did not know why this protocol was not followed in this incident, but S2 may have been under pressure to change R1 before the shift ended as later shifts will sometimes complain to prior shifts if something is not done because later shifts will have to do it. Per the facility’s investigation, both S1 and S2 made multiple attempts to change R1, R1 refused both of them, it was S2 who insisted on changing R1 before end of shift, and S1 and S2 ultimately changed R1 together. LPA interviewed R1 who was confused as to why staff were trying to change their clothes, stated they were distraught during the incident, but that they are now doing fine. LPA interviewed three additional residents who reported that they have not experienced staff being rough. LPA confirmed that both S1 and S2 were background cleared. LPA reviewed S1’s staff file which shows that S1 was trained in mandated reporting requirements, had completed their training, and was terminated on July 31, 2021, for violating the facility’s mandated reporting policy when they did not report S2 being rough with R1. LPA reviewed S2’s staff file which shows that S2 was trained in mandated reporting requirements, had completed their training, and was terminated on July 31, 2021, for roughly handling R1. While the facility responded properly after the incident took place, the facility did not take proper measures to prevent incidents like this through sufficient staff oversight, especially in light of knowing that different shifts were pressuring each other to complete tasks prior to the end of their shift, which in this case resulted in forced care.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20210726164318
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: 12/30/2025
NARRATIVE
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Regarding the allegation of failure to report: it was alleged that the incident with R1 being handled roughly by staff resulting in bruises was not properly reported to R1’s responsible party. The incident report dated July 27, 2021, timely received in the Orange County Regional Office (OCRO), states that local law enforcement, the Long Term Care Ombudsman, the OCRO, and R1’s responsible party were notified of the incident on July 26, 2021, the same day the facility’s investigation into the incident was completed. However, while the incident report indicates that local law enforcement, the Long Term Care Ombudsman, and the OCRO were notified in writing, it does not indicate R1’s responsible party was notified in writing as required. The facility’s report of suspected dependent adult/elder abuse dated July 26, 2021, similarly, does not indicate that R1’s responsible party was notified in writing. While statements from R1’s responsible party, and the facility’s documentation, confirm that R1’s responsible party was told of the incident as of July 26, 2021, all of the information obtained indicates that this notification was only verbal, and not written, as required. Per staff interview, the facility’s policy is to provide only verbal reports to responsible parties and document the notification.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4