306000831-9-2-2026-22-AS-KSGH-DXTMB8-20260911092728

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000831
Report Date: 09/02/2026
Date Signed: 09/02/2026 03:59:23 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
08/27/2026 and conducted by Evaluator Hanna Fuller

COMPLAINT CONTROL NUMBER: 22-AS-20260827145809

FACILITY NAME:	BROOKDALE GARDEN GROVE		FACILITY NUMBER:	306000831
ADMINISTRATOR:	BRISSETH ARRELLANO		FACILITY TYPE:	740
ADDRESS:	10200 CHAPMAN AVE		TELEPHONE:	(714) 636-6453
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92840
CAPACITY:	140	CENSUS: 104	DATE:	09/02/2026
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Ted Dawit		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Facility did not provide requested documents in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hanna Fuller made an unannounced visit to the facility to conduct an investigation into the above mentioned complaint allegation. LPA was greeted and granted entry by staff. LPA met with Health and Welness Director Ted Dawit and discussed the purpose of the visit.

The investigation into the facility allegation of Facility did not provide requested documents in a timely manner revealed the following: It was alleged that Witness #1 (W1) requested Resident #1 (R1) facility file and has not received the records requested. LPA reviewed a certified letter that was received by facility staff on August 12, 2026, requesting for R1s records.

Continue on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Hanna Fuller
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026

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-20260827145809

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: 09/02/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/04/2026 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	87468.2(a)(19) Additional Personal Rights of Residents in Privately Operated Facilities (a)(19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community ...	1 2 3 4 5 6 7	Licensee stated they will send the documents and send proof of documents sent to LPA by POC due date.
	8 9 10 11 12 13 14	standard for photocopies This requirement was not met as evidence by: Interview and records reviewed revealed that the documents were requested on 8/12/26 and as of 9/2/26 have not been sent. This poses a potential health, safety or personal rights risk to residents in care.	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.

SUPERVISOR'S NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Hanna Fuller
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20260827145809

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: 09/02/2026

NARRATIVE

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Interviews with Staff #1 (S1) revealed that they received and signed for the letter on August 12, 2026. Staff #2 (S2) informed LPA that W1 was informed that the request may take some time due to the facility having to go to storage to get R1s file. S2 informed LPA that the documents have not been sent, but they are ready.
Title 22 Division 6 of the California Code of Regulation 87468.2(a)(19) states that photocopied records shall be provided within two business days… Due to the facility receiving the request on August 12, 2026, and on September 2, 2026, the facility still has not fulfilled the request, the preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 are being cited on the attached LIC9099D.

An exit interview was conducted and a copy of this report along with LIC9099D, LIC811 and appeal rights were left at the facility.

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Hanna Fuller
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026

LIC9099 (FAS) - (06/04)

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