<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001000
Report Date: 10/05/2021
Date Signed: 10/05/2021 03:32:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VIEWFACILITY NUMBER:
306001000
ADMINISTRATOR:DANIEL LINESFACILITY TYPE:
740
ADDRESS:5900 CHAPMAN AVETELEPHONE:
(714) 898-3524
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY:160CENSUS: 57DATE:
10/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Daniel LinesTIME COMPLETED:
03:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by Community Care Licensing on 09/20/2021. LPA was greeted and granted entry into the facility by Executive Director Daniel Lines and explained the reason for the visit.

Incident report dated 09/12/2021 indicated Resident 1 (R1) eloped out of the facility to go to McDonald's. R1 phoned the resident's son to advise the trip to McDonald's. The resident's son called the community to advise the resident was out of the community. Facility went to McDonald's to pick up resident who was not there. R1 came back to the facility and was assessed to have no injuries. R1's physician report dated 07/19/2021 indicates R1 is not able to leave the facility unassisted with a diagnosis of MCI. Facility investigation revealed R1 left through a delayed egress door. The delayed egress door alarm goes on between approximately 7-8PM. R1 left the facility around 6:30 PM.

During the visit, LPA spoke with R1 who appeared happy and well taken care of. R1 verbalized being happy and safe at the facility.




Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1