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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001000
Report Date: 02/25/2021
Date Signed: 02/25/2021 03:00:05 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/12/2020 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20200812092607
FACILITY NAME:BROOKDALE VALLEY VIEWFACILITY NUMBER:
306001000
ADMINISTRATOR:DANIEL LINESFACILITY TYPE:
740
ADDRESS:5900 CHAPMAN AVETELEPHONE:
(714) 898-3524
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY:160CENSUS: 57DATE:
02/25/2021
UNANNOUNCEDTIME BEGAN:
02:44 PM
MET WITH:Daniel LinesTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility has inadequate staffing
Personal rights
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman contacted the facility via telephone to deliver findings on a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations with Executive Director Daniel Lines. During the course of the investigation, LPA interviewed staff and witness as well as reviewed and obtained pertinent documentation such as facility extermination records and staff schedule. Regarding the allegation that facility has inadequate staffing and personal rights, the investigation revealed the following: Five out of five staff interviewed denied ever seeing Resident 1(R1) covered in ants or urine. Staff 1 (S1) states seeing ants around the resident's bed on the floor when arriving to care for the resident, date unknown. S1 denies the resident was covered in urine and states resident was clean upon arrival to R1's room. S1 indicates this was a one time occurrence and housekeeping responded to clean the room. R1 is known to keep sweets in the room and on the table adjacent to the bed. LPA observed R1 appeared clean in appearance. R1's physician report dated 07/02/2019 indicates a diagnosis of Mild Cognitive Impairment. R1 has since passed away. Facility provided Ecolab extermination CONTINUED ON LIC 9099C DATED 02/25/2021
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2021
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 2
Control Number 22-AS-20200812092607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 VALLEY VIEW
FACILITY NUMBER: 306001000
VISIT DATE: 02/25/2021
NARRATIVE
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records for the period of February 2020- July 2020. Facility was treated for ants on 2 different occasions, 02/13/2020 and 03/13/2020. Ecolab is on contract with facility and records indicate monthly evaluations. Neither treatment for ants was in R1's room. Facility provided a working staff schedule to LPA indicating staffing levels for the following: First shift includes 3 caregivers, med tech and Wellness Director. Second shift includes 2 caregivers and 1 med tech and third shift is one caregiver and one med tech. All staff interviewed indicated that the staffing levels remain the same and have not fluctuated during the pandemic. Staff schedule matches the levels staff indicated during interview. LPA conducted a FaceTime visit and observed staffing levels that matched facility schedule. Therefore, the allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or is without a reasonable basis.
An exit interview was conducted with Administrator and a copy of this report was provided via email and an electronic email read receipt confirms receiving these.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2