306000831-3-20-2024-22-AS-AORZ-D3SUMC-20240328154204

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000831
Report Date: 03/20/2024
Date Signed: 03/20/2024 03:27:30 PM

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
03/19/2024 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240319093642

FACILITY NAME:	BROOKDALE GARDEN GROVE		FACILITY NUMBER:	306000831
ADMINISTRATOR:	PAMELA BRADLEY		FACILITY TYPE:	740
ADDRESS:	10200 CHAPMAN AVE		TELEPHONE:	(714) 636-6453
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92840
CAPACITY:	140	CENSUS: 89	DATE:	03/20/2024
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Jeri Miles, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility did not provide requested records to authorized representative

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Jeri Miles, Executive Director, and explained the reason for the visit.

It is alleged the facility did not provide requested records to authorized representatives. Based on interview with 2 of 2 staff revealed that they received a request on March 11, 2024, for copies of resident records that included from admission to current. Staff indicated that requestor was not the authorized presentative and facility did not receive an updated change of POA until March 14, 2024. Staff indicated that they started working on request the same day the update was received, and documents were forwarded to the legal department for processing. Copies of pertinent documents revealed that on March 15, 2024, there was

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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-20240319093642

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: 03/20/2024

NARRATIVE

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correspondence to update requestor and with information that records needed to be gathered and records would be available by Tuesday (March 19, 2024) of the following week. Records obtained reflect that on March 19, 2024, records were sent over via email to the requestor. As of today, the records request has been fulfilled and the requestor has obtained copies.

Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations 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 with Executive Director and a copy of this LIC9099 report was left at facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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