306001000-6-23-2021-22-AS-AORZ-C4FVNA-20210629163450

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001000
Report Date: 06/23/2021
Date Signed: 06/23/2021 11:09:39 AM

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
06/21/2021 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20210621150650

FACILITY NAME:	BROOKDALE VALLEY VIEW		FACILITY NUMBER:	306001000
ADMINISTRATOR:	DANIEL LINES		FACILITY TYPE:	740
ADDRESS:	5900 CHAPMAN AVE		TELEPHONE:	(714) 898-3524
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92845
CAPACITY:	160	CENSUS: 61	DATE:	06/23/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Daniel Lines		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff neglect resulted in resident's hospitalization.
Staff neglected resident's calls for help multiple times.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unnanounced complaint visit to initiate an investigation into the above allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Daniel Lines.
During the course of the visit, LPA toured the facility, interviewed Executive Director and reviewed and obtained pertinent documentation such as resident move out report, admission agreement, and physician report. Regarding the allegation that staff neglect resulted in resident's hospitalization and staff neglected resident's calls for help multiple times, the investigation revealed the following: Resident 1(R1) does not currently live at the facility. Facility documentation indicated R1 was at the facility for respite care 05/10/2020 through 05/15/2020. Facility move out report indicates resident moved out on 05/15/2020 and has not been back to the facility since. R1 is not on current roster nor hospital send out sheet.
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 Executive Director and a copy of this report was provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

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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