306000831-4-16-2026-22-AS-LMOA-DTN5D7-20260430195130

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000831
Report Date: 04/16/2026
Date Signed: 04/16/2026 04:45:22 PM

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
07/10/2025 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250710150954

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: 111	DATE:	04/16/2026
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Brisseth Arrellano		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility did not administer medication as prescribed resulting in resident to be hospitalized.

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 allegation. LPA met with Administrator (AD) Brisseth Arrellano and explained the reason for today’s inspection.
The investigation into the allegation that facility did not administer medication as prescribed resulting in resident to be hospitalized revealed the following: During the course of the investigation, Department staff inspected the facility, interviewed AD, residents, witnesses, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Personal Service Plan dated April 25, 2025, R1’s Personal Service Plan dated July 3, 2025, R1’s Home Health Medical Records, R1’s Medication Administration Records, R1’s Garden Grove Hospital Medical Records, and R1’s Kaiser Permanente Medical Records.
It was alleged that R1 was not given their prescribed dosage of Furosemide on July 5 and 6, 2025, experienced increased symptoms including hypotension and fluid on the lungs, and was hospitalized as a result.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

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-20250710150954

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: 04/16/2026

NARRATIVE

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When interviewed, R1 stated they moved into the facility in April 2025, initially handled their own medications, but that they were later reassessed to require medication management by the facility. Review of R1’s Personal Service Plan dated April 25, 2025, confirms that R1 initially handled their own medications and review of R1’s Personal Service Plan dated July 3, 2025, confirms the facility began managing R1’s medications on July 3, 2025. Per R1’s Home Health Medical Records, on May 28, 2025, R1 was prescribed Furosemide 40MG for congestive heart failure with instructions to take one and a half tablets daily and if there is a weight gain of two pounds or greater overnight, 5 pounds over one week, or if R1 experiences swelling or shortness of breath, then to take an additional one and a half tablets for one to three days then return to the previous dose. R1’s Home Health Medical Records also indicate that on July 1, 2025, R1’s doctor issued a new order for R1 to take two tablets of Furosemide 40MG daily on July 3, 4, and 5, 2025 for fluid retention. Interviews with AD and two facility staff revealed that there was confusion with R1’s new order for Furosemide, which was not properly clarified, resulting in a medication error by facility staff where R1 did not receive any Furosemide after the new order ended on July 5, 2025, when R1 should have returned to their previously prescribed dose. R1’s Medication Administration Records do not indicate that Furosemide was ever given to R1, except on July 3, 4, and 5, 2025, where on July 3, 2025, R1 was given two tablets as prescribed, but on July 4 and 5, 2025, R1 was actually given six tablets each day which is triple the prescribed dose.

Per R1’s Garden Grove Hospital Medical Records, on July 8, 2025, R1’s nurse checked on R1 at the facility and noted R1 to be hypoxic, R1 was taken to the emergency room and diagnosed with pulmonary hypertension, hypotension which is likely caused by the pulmonary hypertension, dyspnea, urinary retention, pulmonary edema, and a urinary tract infection, as well as community acquired pneumonia and hyponatremia, R1 was hospitalized, and R1 was discharged to Kaiser Permanente hospital on July 10, 2025. Per R1’s Kaiser Permanente Medical Records, R1 was admitted on July 10, 2025, for acute on chronic hypoxemic respiratory failure, R1’s diagnoses included pulmonary hypertension, interstitial lung disease, cor pulmonale, coronary artery disease without angina, presence of stent diastolic heart failure, chronic hypoxemic respiratory failure, bronchiectasis, and R1 was discharged back to the facility on July 13, 2025. Per a witness from Kaiser Permanente, on July 7, 2025, R1’s home health nurse visited R1 at the facility and discovered that R1 had not received their prescribed dose of Furosemide. This witness also confirmed that R1’s doctor at Kaiser Permanente hospital determined that R1 not receiving their Furosemide as prescribed caused their hypotension and fluid on the lungs. The information obtained corroborated the allegation.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250710150954

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: 04/16/2026

NARRATIVE

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During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is 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. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20250710150954

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: 04/16/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/17/2026 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a)… (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by :Based on interviews and documents, the licensee did not ensure	1 2 3 4 5 6 7	Licensee stated that they will retrain staff on medication administration and submit proof to LPA by POC due date.
	8 9 10 11 12 13 14	R1 received assistance with medications by not giving R1 their Furosemide on multiple days and giving R1 triple their prescribed dose on two days resulting in hospitalization, which poses an immediate health risk to persons in care. CIVIL PENALTY ASSESSED.	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.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

LIC9099 (FAS) - (06/04)

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