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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000831
Report Date: 02/13/2025
Date Signed: 02/13/2025 11:55:54 AM

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
06/05/2024 and conducted by Evaluator Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240605094352
FACILITY NAME:BROOKDALE GARDEN GROVEFACILITY NUMBER:
306000831
ADMINISTRATOR:JERI MILESFACILITY TYPE:
740
ADDRESS:10200 CHAPMAN AVETELEPHONE:
(714) 636-6453
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY:140CENSUS: 104DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Jeri Miles-AdministratorTIME COMPLETED:
12:11 PM
ALLEGATION(S):
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Facility staff falsified the resident's Physician Report
Resident was unlawfully retained in Memory Care
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Brandon Lopez conducted an unannounced visit to deliver findings on the above allegations received on June 05, 2024. LPAs were greeted and granted entry into the facility and met with Administrator (AD) Jeri Miles. LPAs explained the reason for the visit.

This Department has investigated the complaint alleging that facility staff falsified the resident's Physician Report. Resident 1 (R1) was admitted to the facility on September 22, 2023. Documents reviewed included the Physician Report (LIC602) dated February 12, 2024, for R1. Per Physician report R1’s diagnoses are Hypertension and Major Depressive Disorder. Per Physician report dated February 12, 2024, R1 does not have a diagnosis of Dementia and is able to leave the facility unassisted. During the investigation LPA reviewed documents including the Physician Report dated February 11, 2024, for R1. Per Physician report dated February 11, 2024, R1 has a diagnosis of Dementia and is not able to leave the facility unassisted. During the course of the investigation LPA conducted interviews with witness 1 (W1), who is a Scan Associate General Counsel.

CONTINUED ON LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20240605094352
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: 02/13/2025
NARRATIVE
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Per W1 Scan’s Nurse Practitioner (NP) was not working on February 11, 2024, and stated that the NP completed the Physician report for R1 on February 12, 2024.

Regarding the allegation that Resident was unlawfully retained in Memory Care, the following was revealed: During the investigation LPA reviewed documents including the Personal Service Plan dated February 12, 2024, for R1. Per Personal Service Plan under comments, it states Resident with Scan as of move in. During the course of the complaint LPA reviewed documents including the Senior Doc New Provider orders dated February 10, 2024, for R1. Per New Provider orders it states patient may remain in the community in a locked/secured area/unit. LPA reviewed the Scan monthly visit dated February 12, 2024, for R1. Per Scan notes patient was seen and evaluated inside the Memory Care. During the course of the investigation LPA reviewed the Brookdale Garden Grove Progress Notes dated February 10, 2024, for R1. Per Progress notes is states R1 moved from Assisted Living to Memory Care same day and LIC602 to be completed today by provider to reflect change. Per Physician report dated February 12, 2024, R1 does not have a diagnosis of Dementia and is able to leave the facility unassisted.



Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: facility staff falsified the resident's Physician Report and Resident was unlawfully retained in Memory Care are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

An exit interview was conducted with AD Miles and a copy of this report along with the Appeal Rights were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240605094352
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: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2025
Section Cited
CCR
87207
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87207 False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This regulation was not met as evidence by: Based on interviews conducted and
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Licensee agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.
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records reviewed the Physician report dated 02/11/24 was not filled out by Scan's Nurse Parctitioner as Nurse Practitoner was not working on 02/11/24. This poses an immediately risk to resident’s health and safety.
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Type B
02/20/2025
Section Cited
CCR
87468(a)
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87468(a) Personal Rights. Residents in residential care facilities for the elderly shall have personal rights which include, but are not limited to, those listed in Sections 87468.1, Personal Rights of Residents in All Facilities, and 87468.2, Additional Personal Rights of
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Licensee agrees to read regulation and sign a statement of understanding, provide in-service training and forward proof to LPA by POC due date.
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Residents in Privately Operated Facilities, as applicable to the facility. This regulation was not met as evidence by: Based on interviews conducted and records reviewed the facility did not communicate with R1's Authorized Representative prior to placing R1 in Memory Care. CONT...
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Per Physician report dated 02/12/24, R1 does not have a diagnosis of Dementia and is able to leave the facility unassisted.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3