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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001000
Report Date: 02/27/2023
Date Signed: 03/01/2023 12:34:13 PM

Substantiated


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
02/14/2023 and conducted by Evaluator Kimberly Lyman
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230214144423
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: 55DATE:
02/27/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Melissa WeibelTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Lack of staffing resulted in facility not meeting resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility by Executive Director (ED) Melissa Weibel and explained the reason for the visit. Wellness Director Michelle Drinkard arrived during the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as physician report and staff achedule. Regarding the allegation that lack of staffing resulted in facility not meeting resident's needs, the investigation revealed the following: Four out of four staff and six out of six residents confirm staffing issues during the time frame alleged in complaint. Four out of four staff indicate Resident 1 (R1) was a 2 person assist and sometimes there would be only one caregiver working. All staff interviewed state staffing issues are improved as of time of complaint filing. Facility does not provide the pendant response log to the department. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted with ED and a copy of this report was provided as well as appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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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Control Number 22-AS-20230214144423
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2023
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care..This requirement is not being met as evidenced by:
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Licensee to provide a written plan on how to ensure facility staff is sufficient to meet the residents needs and forward proof to LP by POC due date.
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Based on interviews conducted, Licensee failed to ensure facility staff is sufficient to meet the resident's needs. This poses an immediate health and safety risk to residents 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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
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