306000831-7-16-2026-22-AS-LMOA-DX37JG-20260817214215

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000831
Report Date: 07/16/2026
Date Signed: 07/16/2026 08:30:21 AM

Unsubstantiated

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
11/19/2025 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20251119151521

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: 108	DATE:	07/16/2026
		UNANNOUNCED	TIME BEGAN:	07:45 AM
MET WITH:	Ted Dawit		TIME COMPLETED:	08:45 AM

ALLEGATION(S):

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Lack of care and supervision resulted in resident sustaining a fracture

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 Wellness Director (WD) Ted Dawit on behalf of Administrator (AD) Brisseth Arrellano and explained the reason for today’s inspection.

The investigation into the allegation of lack of care and supervision resulted in resident sustaining a fracture 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) hospice medical records, and R1’s facility care plan.

It was alleged that R1, who is on hospice care, was complaining of pain in their left upper arm and was diagnosed with an impaction fracture on November 12, 2025.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

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-20251119151521

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: 07/16/2026

NARRATIVE

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Review of R1’s hospice medical records revealed that an x-ray was taken on November 13, 2025, of R1’s left shoulder which revealed that the bones of R1’s shoulder are osteoporotic and there is an impaction of the surgical neck. When interviewed, AD and four additional facility staff denied witnessing or being aware of any recent falls by R1 at the facility. However, facility staff reported that R1 had a fall years ago and that R1’s left shoulder has had limited mobility for years. One facility staff noted that the bones in R1’s upper left arm seemed to make noises during changes, reported this to hospice in 2023, and was advised by hospice that the sounds were related to R1’s chronic arthritis. R1’s hospice medical records indicate R1 has been on hospice since July 28, 2023, and hospice staff give R1 sponge baths. An interview was attempted with R1, but R1 was unable to participate in the interview. When interviewed, R1’s family stated that R1 had pain in their shoulder for a month and a half prior to the x-ray. However, R1’s private caregiver, who is present with R1 four to five days a week for four to five hours a day and has been working with R1 since their admission, denied witnessing or being aware of any recent falls by R1 at the facility. The private caregiver further denied observing or hearing R1 report any recent complaints of pain in their arm or shoulder. When interviewed, three hospice staff also denied witnessing or being aware of any recent falls by R1 at the facility. While R1 sustained a fracture at the facility, it is unclear when R1 sustained the fracture and the information obtained did not corroborate that it was due to lack of care and supervision.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC9099 (FAS) - (06/04)

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