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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000831
Report Date: 06/30/2021
Date Signed: 06/30/2021 02:56:56 PM

Document Has Been Signed on 06/30/2021 02:56 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:PAMELA BRADLEYFACILITY TYPE:
740
ADDRESS:10200 CHAPMAN AVETELEPHONE:
(714) 636-6453
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 140CENSUS: 74DATE:
06/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Michael Sokolowski TIME COMPLETED:
11:00 AM
NARRATIVE
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During the investigation of compliant number 22-AS-20210623125429 LPA Norman Woodridge observed the following deficiencies. Per Title 22 Division 6 of the California Code of Regulations that are noted on LIC 809D:


An exit interview was conducted. This report was reviewed with Michael Sokolowski, Executive Director, and a copy was provided along with a copy of the appeal rights.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Norman Woodridge
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2021
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 06/30/2021 02:56 PM - It Cannot Be Edited


Created By: Norman Woodridge On 06/30/2021 at 10:53 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BROOKDALE GARDEN GROVE
FACILITY NUMBER: 306000831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2021
Section Cited
CCR
87465(h)(2)

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Incidental Medical and Dental Care - Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

The regulation was not met as evidence by:
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The administrator immediately locked the cart. Administrator stated that all staff will be trained on proper medication storing precedures. The proof of training will be sent to CCLD by Monday, July12, 2021.
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Facility did not ensure that centrally stored medicines were kept safe, locked, and only accessable to persons responsible for the supervision of medications. The LPA observed medication cart unlocked at the entrance to demetia care unit. This poses an immediate risk to the health and safety of the 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.
SUPERVISOR'S NAME:Marina Stanic
LICENSING EVALUATOR NAME:Norman Woodridge
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2021


LIC809 (FAS) - (06/04)
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