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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001000
Report Date: 07/11/2025
Date Signed: 07/11/2025 03:07:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
06/05/2025 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250605124628
FACILITY NAME:BROOKDALE VALLEY VIEWFACILITY NUMBER:
306001000
ADMINISTRATOR:JOHN GOODWINFACILITY TYPE:
740
ADDRESS:5900 CHAPMAN AVETELEPHONE:
(714) 898-3524
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY:160CENSUS: 68DATE:
07/11/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Christine Perez, Executive DirectorTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Facility is mismanaging resident's medication
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegation listed above. LPA was greeted and granted entry by facility front desk staff after introducing himself and stating the purpose of the visit. Facility Executive Director Christine Perez was present and assisted with the visit.

An initial investigation visit has taken place on June 11, 2025. During the visit, LPA requested the facility current census as well as the identification of residents on medication management and residents self-administering. A random selection of records for three residents on self-administration and three residents on medication management was requested, obtained and reviewed during the visit. Medication administration records and centrally stored medication also reviewed for the residents in question. Additionally, LPA conducted or attempted four staff interviews and four resident interviews. Additional witness interviews were conducted via telephone during the investigation.
CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
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 3
Control Number 22-AS-20250605124628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BROOKDALE VALLEY VIEW
FACILITY NUMBER: 306001000
VISIT DATE: 07/11/2025
NARRATIVE
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CONTINUED FROM LIC9099
During the present visit, LPA requested to review additional files as well as the medication central storage.

Regarding the allegation that Facility is mismanaging resident's medication, the following has been concluded: Based on interviews conducted, records reviewed and observations made at the facility, it was determined that following R1's admission on May 23, 2025, initial difficulties filling prescriptions written at the skilled nursing facility where R1 was admitted previously resulted in multiple self-administered doses for several medications to be missed. At the time of the initial visit however, the issues had been resolved with the assistance of R1's responsible party and prescribed medications were observed to be adequately present in the facility's central storage. A random review of prescribed medications for other facility residents evidenced that one prescription for resident R2 had not been administered for four days (from June 9 until June 13, 2025) due to apparent errors made by the pharmacy during the refill. Despite measures described by staff to anticipate on upcoming refills, R2 could not be administered one of their medications for multiple days before the refill was finally issued and delivered on June 13, 2025. During the present visit, all medications reviewed are adequately present in central storage.

However, based on the evidence gathered during the investigation, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A Type A deficiency is being cited on the attached form LIC9099-D.

An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250605124628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BROOKDALE VALLEY VIEW
FACILITY NUMBER: 306001000
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2025
Section Cited
CCR
87465(a)(4)
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Per California Code of Regulations Section 87465(a)(4) on Incidental Medical and Dental Care: "The licensee shall assist residents with self-administered medications as needed". This requirement was not met as evidenced by:
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Licensee will conduct an in-service training with personnel helping with self-administration of medication. Proof of training and attendance to be provided to LPA.
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Based on records reviewed, observation and interviews conducted, at least two residents did not receive multiple doses of prescription medication due to supply issues. This constitutes an immediate risk to the health, safety or personal rights of individuals in care.
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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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3