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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001000
Report Date: 03/04/2024
Date Signed: 03/04/2024 01:16:48 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
02/26/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240226161612
FACILITY NAME:BROOKDALE VALLEY VIEWFACILITY NUMBER:
306001000
ADMINISTRATOR:MELISSA WEIBELFACILITY TYPE:
740
ADDRESS:5900 CHAPMAN AVETELEPHONE:
(714) 898-3524
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY:160CENSUS: 49DATE:
03/04/2024
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Patricia PerezTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility staff are not properly trained
Facility is unsanitary
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as staff training. Regarding the allegations that facility staff are not properly trained and facility is unsanitary, the investigation revealed the following: On 02/12/2024, Staff 1 (S1) administered a vaginal suppository to Resident 1 (R1) per Health and Wellness Director's (HWD) instruction. LPA reviewed S1's training records during the visit and staff had required annual training. While the staff had medication training, S1 is not a skilled professional as required by title 22 regulations. Facility was alerted to the situation and the Health and Wellness Director was terminated on 02/26/2024. S1 was provided re-training. On the evening of 02/15/2024, Resident 1 (R1) vomited and requested assistance from S2 cleaning up the floor and the resident's wheelchair. Per interview with resident and facility documentation, S2 stated that the CONTINUED ON LIC 9099C DATED 3/4/2024
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: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024
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 4
Control Number 22-AS-20240226161612
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: 03/04/2024
NARRATIVE
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morning shift will clean it up and left the floor and wheelchair soiled. The next morning the soiled areas were cleaned by morning staff. S2 was put into corrective action on 02/19/2024 for the incident. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are 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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
02/26/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240226161612

FACILITY NAME:BROOKDALE VALLEY VIEWFACILITY NUMBER:
306001000
ADMINISTRATOR:MELISSA WEIBELFACILITY TYPE:
740
ADDRESS:5900 CHAPMAN AVETELEPHONE:
(714) 898-3524
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY:160CENSUS: 49DATE:
03/04/2024
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Patricia PerezTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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9
Facility failed to safeguard resident belongings
INVESTIGATION FINDINGS:
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12
13
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician reports. Regarding the allegation that facility failed to safeguard resident belongings, the investigation revealed the following: Resident 1's (R1) physician report dated 09/15/2023 indicated resident was unable to manage or store medications. On 02/15/2024, Staff 3 removed medications from resident's room per physician order. Facility fascilitated a new physician assessment and physician report dated 02/20/2024 indicates resident can now manage and administer own medications. Resident's medications were returned to resident and LPA observed medications back in the room. Based on record review and interviews conducted, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis.
An exit interview was conducted, and a copy of this report was provided.
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: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 22-AS-20240226161612
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: 03/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2024
Section Cited
CCR
87622(a)(2)
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The licensee shall be permitted to accept or retain a resident..,suppositories shall be permitted if administered according to physician's orders by either the resident or an appropriately skilled professional. This requirement is not being met as evidenced by:
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Licensee to forward a statement of understanding of the regulation to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure an appropriately skilled profession administered a suppository. S1 administered a suppository to R1 and is not a skilled professional. This poses an immediate health and safety risk to residents in care.
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Type B
03/18/2024
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not being met as evidenced by:
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Licensee to provide an in-service to staff and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure facility is clean and sanitary. S2 failed to clean up resident's soiled floor and wheelchair. This poses a potential 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: 03/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4