306000831-5-14-2026-22-AS-APAO-DVS6YN-20260707211349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000831
Report Date: 05/14/2026
Date Signed: 05/14/2026 08:35:25 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
12/19/2024 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20241219203507

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: 112	DATE:	05/14/2026
		UNANNOUNCED	TIME BEGAN:	07:44 AM
MET WITH:	Brisseth Arrellano		TIME COMPLETED:	08:50 AM

ALLEGATION(S):

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Resident sustained multiple falls while in care.
Staff are not properly supervising residents who are a fall risk.

INVESTIGATION FINDINGS:

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It was alleged that resident sustained multiple falls while in care and that staff are not properly supervising resident who is a fall risk. During the course of the investigation, the Department conducted interviews and attempted to interview R1 and R1’s responsible party; however, those attempts were unsuccessful. A review of facility records provided to LPA Lee on 3/23/2026 revealed no documentation identifying R1 as a fall risk, despite progress notes indicating that R1 experienced a total of 14 falls between 10/10/2024 and 01/08/2025. Documentation for these incidents reflects that R1 sustained injuries including head trauma, bumps, bleeding, bruising, and skin lacerations. Additionally, an After Visit Summary dated 01/08/2025 indicates that R1 was treated following a fall and diagnosed with a closed fracture of multiple ribs on the right side.

Further review of R1’s Personal Service Plan dated 09/11/2024 indicates that fall prevention measures were not addressed. According to the facility’s Fall Management and Recovery Policy, a fall risk evaluation is to be completed upon move-in or as required by state regulation.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

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-20241219203507

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: 05/14/2026

NARRATIVE

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The policy also requires that all witnessed or unwitnessed falls be documented in the Brookdale Incident Reporting System (BAIRS), that a post-fall evaluation be conducted to identify interventions to prevent future falls, and that the service plan be reviewed and updated accordingly. Additionally, the policy requires that falls be tracked and trended for quality improvement purposes.

Based on records provided by the facility, there was no documentation demonstrating that a fall risk assessment was completed upon R1’s admission. Furthermore, there was no evidence that post-fall evaluations were conducted following R1’s repeated falls, nor that interventions and or fall prevention plan were implemented or documented. The Personal Service Plan was not updated to reflect R1’s history of falls and related injuries. Overall, the facility did not follow its own policies and procedures regarding fall risk assessment, post-fall evaluation, care planning, and documentation for a resident with a history of falls.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

An Exit Interview was conducted with (FDA) Arrellano and a copy of this report was provided to the facility via email. A certified copy will be sent to the facility mailing address.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20241219203507

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: 05/14/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/22/2026 Section Cited CCR 87466	1 2 3 4 5 6 7	The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs…the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidence by:	1 2 3 4 5 6 7	As a plan of correction, the facility will also ensure that all residents who experience frequent falls are reassessed, and that appropriate fall prevention plans are developed and implemented in accordance with the facility’s Fall Management and Recovery Policy.
	8 9 10 11 12 13 14	Based on the documents reviewed during the investigation, the facility did not ensure that the resident was reassessed despite multiple falls. There was no evidence that post-fall evaluations were conducted following R1’s repeated falls, nor that appropriate interventions or a fall prevention plan were implemented or documented. This condition poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	In addition, the Administrator will review the cited regulation and submit a written statement to LPA Lee acknowledging understanding and compliance with the regulation due by 05/22/2026 end of day at 5:00 PM.
Type B 05/22/2026 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by	1 2 3 4 5 6 7	As a plan of correction (POC), the Administrator will review the cited regulation and submit a written statement to LPA Lee acknowledging understanding and compliance with the regulation due by 05/22/2026 end of day at 5:00 PM.
	8 9 10 11 12 13 14	Based on the documents reviewed during the investigation, the facility did not ensure that R1 received appropriate care and supervision despite experiencing multiple falls, which resulted in injuries, including two rib fractures. This poses a potential health and safety risk for residents in care.	8 9 10 11 12 13 14

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: 05/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

LIC9099 (FAS) - (06/04)

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