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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000831
Report Date: 06/24/2024
Date Signed: 06/24/2024 04:23:36 PM


Document Has Been Signed on 06/24/2024 04:23 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:JERI MILESFACILITY TYPE:
740
ADDRESS:10200 CHAPMAN AVETELEPHONE:
(714) 636-6453
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY:140CENSUS: 89DATE:
06/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:11 PM
MET WITH:Jeri Miles, AdministratorTIME COMPLETED:
03:25 PM
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On today's date, LPA Quiroz called Administrator (AD) Jeri Miles via telephone to discuss amended report for complaint control #22-AS-20240226102932 dated 6/21/2024 on page 2 of 2. LPA Quiroz discussed amended report with AD Jeri Miles.

An exit interview was conducted with AD Miles via telephone, and it was explained that a copy of amended report for complaint control #22-AS-20240226102932 and today's report would be emailed to facility. An electronic email read receipt confirms receiving of the report. AD Miles agreed to print the amended report and today's case management report, sign and email copy including signatures to LPA Quiroz.


SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024
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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