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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001000
Report Date: 06/17/2024
Date Signed: 06/17/2024 02:18:53 PM


Document Has Been Signed on 06/17/2024 02:18 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:BROOKDALE VALLEY VIEWFACILITY NUMBER:
306001000
ADMINISTRATOR:PATRICIA PEREZFACILITY TYPE:
740
ADDRESS:5900 CHAPMAN AVETELEPHONE:
(714) 898-3524
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY:160CENSUS: 50DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Patricia PerezTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Executive Director Patricia Perez and explained the reason for the visit. The facility is a two story building with 81 resident rooms. LPA and the Executive Director toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA observed the first floor of the facility is well lit and the hallways are free of obstacles and hazards. All fire extinguishers on the first floor are fully charged. LPA observed cleaning supplies are kept locked in a storage closet. Facility does not have a memory care unit and does not have any delayed egress exits. The dining room is clean and has enough room to accommodate the residents. LPA observed the kitchen is clean and organized. LPA observed a two day perishable and a seven day non-perishable food supply on hand in the kitchen. The refrigerators and the freezer were at the required temperature. The fire extinguisher in the kitchen is fully charged. LPA inspected 3 resident rooms on the first floor. LPA observed the resident rooms had the required furnishings and bed linens. LPA observed the bathrooms were clean and operational. Hot water measured 105.0 to 106.0 degrees Fahrenheit. LPA observed residents participating in a trivia game in the activity room during the visit. LPA tested the signal system in 2 rooms, one the second floor and one on the first floor, the response time was 3 minutes. There is an outdoor patio with shaded seating outside of the dining room. The patio has a yard with a small circular walkway that residents can use to walk. No bodies of water observed. The emergency exit gates in the outdoor area are operational. No obstacles or hazards observed in the patio. LPA and the Executive Director toured the second floor. LPA observed that each stairway has an emergency evacuation chair. LPA inspected 3 resident rooms on the second floor. LPA observed the resident rooms had the required furnishings and bed linens. LPA observed the bathrooms were clean and operational. Hot water measured 105.0 to 106.0 degrees Fahrenheit. LPA observed all fire extinguishers on the second floor are fully charged. There is a patio with shaded seating on the second floor. The facility has a library on the second floor with books for the residents to read. No obstacles or hazards observed on the second floor. LPA reviewed 5 resident files no discrepancies observed. All smoke detectors/carbon monoxide detectors in the resident rooms inspected tested operational.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/17/2024
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The last emergency drill was conducted on May 6, 2024. LPA reviewed 5 resident medications, no discrepancies observed. LPA reviewed 5 staff files, all 5 staff members had the required 20 hours of annual training. No discrepancies observed in the staff files. No deficiencies observed during the visit. An exit interview conducted and a copy of the report provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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