306001000-10-3-2023-22-AS-SSAS-CWJN8M-20231012101432

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001000
Report Date: 10/03/2023
Date Signed: 10/03/2023 11:11:30 AM

Unfounded

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
09/01/2023 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230901162928

FACILITY NAME:	BROOKDALE VALLEY VIEW		FACILITY NUMBER:	306001000
ADMINISTRATOR:	MELISSA WEIBEL		FACILITY TYPE:	740
ADDRESS:	5900 CHAPMAN AVE		TELEPHONE:	(714) 898-3524
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92845
CAPACITY:	160	CENSUS: 64	DATE:	10/03/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Melissa Weibel - Executive Director		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Staff do not ensure special dietary restrictions are followed for resident in care
Staff did not ensure resident received medical treatment in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to deliver the findings on the complaint allegations mentioned above. LPA Haley met with Executive Director (ED) Melissa Weibel and explained the reason for the visit. During the investigation, staff interviews were conducted, documents were reviewed, and observations were made during the unannounced visit.

Regarding the allegation: Staff do not ensure special dietary restrictions are followed for resident in care

Document review revealed Resident 1 (R1) was not on a special diet at the time the complaint was filed September 1, 2023. R1 was on a texture modified diet when the resident first moved into the facility in July 7, 2023. However, on August 1, 2023, R1 received a physician’s order for a regular diet with no texture modifications. During interviews, it was discovered R1 doesn’t like sweets and doesn’t eat sweet food.
During the visit, observations were made that contradict the allegation above.
Continued on LIC9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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-20230901162928

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: 10/03/2023

NARRATIVE

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While observing R1’s room, there were no sweets present, flavored water was the only item in the refrigerator, and “Sweet’ N Low” packets were observed in a plastic container with some tea bags. During an inspection of the kitchen, a dietary restrictions board was observed. Resident photos are placed on color coded cards with details of their diet for kitchen personnel to follow.
5 of 8 witnesses interviewed during the investigation confirmed dietary restrictions are followed.

Regarding the allegation: Staff did not ensure resident received medical treatment in a timely manner

5 of 8 witnesses denied the allegation. It was discovered the R1 complained of shoulder pain and a Med tec was sent to assess the resident. During the assessment, R1 complained of shoulder pain and dizziness. When the Wellness Director came to assess the resident, there were still complains of shoulder pain and the resident was offered Tylenol for the pain. Paramedics were eventually called, and transported R1 to the hospital at the request of a family member who was on the phone during the entire time a aware of what was going on. R1 was sent to Los Alamitos Medical Center for shoulder pain and returned to the facility the same day (8.31.23) with no new orders.

Based on the information gathered during the investigation through interviews, document review, and observation. The allegations mentioned above are deemed UNFOUNDED, meaning the allegations are 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.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC9099 (FAS) - (06/04)

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