306000831-11-7-2023-22-AS-AORZ-CY423E-20231130160213

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000831
Report Date: 11/07/2023
Date Signed: 11/07/2023 04:04:29 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/01/2020 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201201100053

FACILITY NAME:	BROOKDALE GARDEN GROVE		FACILITY NUMBER:	306000831
ADMINISTRATOR:	ROBERT JAKINI		FACILITY TYPE:	740
ADDRESS:	10200 CHAPMAN AVE		TELEPHONE:	(714) 636-6453
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92840
CAPACITY:	140	CENSUS: 96	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Patricia Jimenez, Business Office Manager		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

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-Resident was inappropriately pushed while in care
-Residents sustained unexplained injuries while in care
-Staff speak inappropriately towards a resident while in care
-Residents sustains multiple falls while in care

INVESTIGATION FINDINGS:

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On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to the facility to follow up on allegations listed above. LPA Quiroz was greeted and granted entry by Front Desk Receptionist and met with Patricia Jimenez, Business Office Manager and discussed purpose of today's visit.
The 10 day visit was conducted by LPA Quiroz on 12/08/2020 virtually due to COVID-19 Pandemic. A follow up investigation visit was conducted by LPA Quiroz on 8/8/2023.
During the course of this investigation, LPA Quiroz conducted interviews with interviewees consisting of staff, clients, witnesses and reviewed documentation but not limited to Personnel Report LIC 500, staff schedules,resident roster, Physician Reports, Identification Forms and Needs and Services Plans.
It is alleged that “Resident was inappropriately pushed while in care,” “Residents sustained unexplained injuries while in care,” “Staff speak inappropriately towards a resident while in care” and “Residents sustains multiple falls while in care.”
CONTINUED ON NEXT LIC 9099-C PAGE...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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-20201201100053

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 GROVE	FACILITY NUMBER: 306000831
	VISIT DATE: 11/07/2023

NARRATIVE

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CONTINUED...During the course of the investigation, the investigation revealed the following: Resident 1(R1) was admitted to the facility on 9/30/2017. (R1s) Physician report dated 11/10/2020 indicates primary diagnose as Parkinson’s disease and secondary diagnose as Progressive Supranuclear Disease (PSP). PSP is a condition that causes symptoms similar to those of Parkinson's disease involving damage to many cells of the brain including the part of the brainstem where cells that control eye movement are located and the area of the brain that controls steadiness when you walk is also affected.
On 12/8/2020 while conducting 10 day visit, interviewee indicated that (R1) was noted to be wheelchair dependent stating “Staff have reported observing (R1) trying to get out of their wheelchair and confused and disoriented.” Documentation review of physician report dated 11/10/2020 indicates (R1) to be wheel chair dependent and confused and disoriented. Three of five staff interviewed indicated not knowing or meeting (R1) due to recent employment with the facility.
Ten of ten interviewees consisting of staff, residents and other witnesses indicated staff speak appropriately to residents in care as evidenced by treating residents with dignity and respect.
The department has investigated the allegations listed above.

Therefore based on the preponderance of evidence gathered through interviews conducted, documentation review and observations conducted by LPA Quiroz, the allegations that the “Resident was inappropriately pushed while in care,” “Residents sustained unexplained injuries while in care,” “Staff speak inappropriately towards a resident while in care” and “Residents sustains multiple falls while in care” were found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted with Business Office Manager Patricia Jimenez and a copy of this report, along with LIC 811- Confidential Names were provided at exit.
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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

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