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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000831
Report Date: 12/07/2023
Date Signed: 12/07/2023 12:20:26 PM


Document Has Been Signed on 12/07/2023 12:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 GROVEFACILITY NUMBER:
306000831
ADMINISTRATOR:PAMELA BRADLEYFACILITY TYPE:
740
ADDRESS:10200 CHAPMAN AVETELEPHONE:
(714) 636-6453
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY:140CENSUS: 87DATE:
12/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Jeri Miles- Executive DirectorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) arrived unannounced for a Case Management visit. LPA met with Executive Director Jeri Miles and explained the reason for the visit.

During today's visit, LPA interviewed Resident #1 (R1) in connection to Complaint Control Number: 22-AS-20230919083629 and obtained records.

An exit interview was conducted with Executive Director Jeri Miles, and copy of this report and LIC811 were provided at the end of the visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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