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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000831
Report Date: 08/09/2024
Date Signed: 08/09/2024 03:11:54 PM


Document Has Been Signed on 08/09/2024 03:11 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: 92DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Jeri MilesTIME COMPLETED:
03:25 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad, Samer Haddadin, and William Vanegas for the purpose of conducting a Required – 1 Year Inspection. LPAs met with Administrator (AD) Jeri Miles and discussed the purpose of the inspection.

LPAs reviewed Infection Control requirements. At about 9:00AM, LPAs and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a large commercial facility. Facility is composed of a single, two-story building with a delayed egress memory care unit on the first floor, a commercial kitchen and large dining room on the first floor, a medication room on the second floor, and resident rooms on all floors, along with multiple common areas, storage rooms, and a large central courtyard and a smaller courtyard dedicated to memory care with shaded seating for residents. There are a total of 115 resident rooms. Resident Bedrooms: the 12 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 12 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 107 degrees F and 120 degrees in the 12 resident bathrooms inspected, after corrections. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have been paid. At about 10:30AM, LPAs reviewed 6 resident files and 6 staff files, interviewed 6 residents and 6 staff, and inspected medications for 6 residents. Facility does not handle resident money.

CONTINUED
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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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Document Has Been Signed on 08/09/2024 03:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the faucets in rooms 103, 104, 115, and 243 tested at 126, 133, 124, and 129 degrees F, respectively, and rooms 103, 104, and 115 are in memory care, which poses an immediate safety risk to persons in care. During the inspection, the licensee adjusted the temperature and LPA confirmed.
POC Due Date: 08/10/2024
Plan of Correction
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Licensee stated they will begin conducting regular water temperature checks and will submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/09/2024
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During the inspection, LPAs and AD observed the following: based on observation, the faucets in rooms 103, 104, 115, and 243 tested at 126, 133, 124, and 129 degrees F, respectively, and rooms 103, 104, and 115 are in memory care.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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