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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001000
Report Date: 05/05/2022
Date Signed: 05/11/2022 06:30:21 PM


Document Has Been Signed on 05/11/2022 06:30 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 VALLEY VIEWFACILITY NUMBER:
306001000
ADMINISTRATOR:DANIEL LINESFACILITY TYPE:
740
ADDRESS:5900 CHAPMAN AVETELEPHONE:
(714) 898-3524
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY:160CENSUS: 54DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Esmiralda BehonskyTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct a.n Annual visit. Upon arrival LPA met with Health and Wellness Director Esmiralda Behonsky. Administrator Daniel Lines was not present but was contacted in regards to LPA's visit and arrived at approximately 11:30 am. The focus of the visit was Infection Control. LPA toured the facility with Mrs. Behonsky and the following was observed:
Covid signs were posted near the elevator at the front entrance. LPA's temperature was taken upon arrival and a sign in sheet was available and completed. The Concierge asked for LPA's vaccination card. LPA toured the hallways as well as the dining room and shared restrooms. Hand sanitizing stations were present and several more were to be placed throughout the building. Restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present and in sufficient supply. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Residents were observed conducting a trivia activity as well as resting in their rooms and visiting with family. Staff were preparing for a Cinco De Mayo social. Social Distancing and masks were observed. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured medication room for resident medication and files. All residents have at least a 30 day supply. Covid Testing is conducted every Friday at this time due to recent positive cases. Resident temperatures are taken once a day.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and handwashing for staff. Administrator is reminded to review ASC PINS in regards to Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment, as well as updated Staff Testing. No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to Daniel Lines.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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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