306001000-12-27-2024-22-AS-SHAN-DCCQQ8-20241227112154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001000
Report Date: 12/27/2024
Date Signed: 12/27/2024 11:22:06 AM

Document Has Been Signed on 12/27/2024 11:22 AM - 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 VIEW		FACILITY NUMBER:	306001000
ADMINISTRATOR/ DIRECTOR:	PATRICIA PEREZ		FACILITY TYPE:	740
ADDRESS:	5900 CHAPMAN AVE		TELEPHONE:	(714) 898-3524
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92845
CAPACITY: 160	TOTAL ENROLLED CHILDREN: 0	CENSUS: 62	DATE:	12/27/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:10 AM
MET WITH:			TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced case management visit .LPA was greeted and granted entry into the facility by concierge and later met with Executive Director (ED) Jeri Miles.

The purpose of the visit is to follow-up on an incident report that was sent by this facility to Community Care Licensing; the incident report stated a resident (R1) was hospitalized and later found out R1 had fracture to medial right tibia after sustaining a fall in own room at the facility. LPA reviewed resident’s file and LIC-602 (Physician’s Report) and observed that R1 is ambulatory and can transfer to and from bed and can manage their own medication. LPA also reviewed the pendent call history for R1 and observed that R1 had placed 10 service calls in the past 30 days with the 20^th of December being the last day.

LPA confirmed that R1 still at the hospital and had gone into surgery. Its unknown when R1 will be back to facility.

LPA interviewed three staff member and three of three confirmed that R1 is ambulatory and did attend a happy hour inside the facility where R1 had two small cups of wine prior to going back to her room.

No deficiencies are being cited on today's visit. An exit interview was conducted with ED and a copy of the report was provided.

Alisa Ortiz	TELEPHONE: (714) 703-2855
Samer Haddadin	TELEPHONE: (714) 790-2096
	DATE: 12/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024

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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