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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001000
Report Date: 01/08/2025
Date Signed: 01/08/2025 03:11:47 PM

Unsubstantiated


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
02/05/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240205143436
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: 61DATE:
01/08/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Chiquita MorrisTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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lack of care and supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as staff schedule. Regarding the allegation of lack of care and supervision, the investigation revealed the following: Facility schedule indicates three caregivers, one med tech and one coordinator for 1st and 2nd shift and one caregiver/ med tech for the overnight shift. Six out of six staff and four out of four residents state care and supervision is being provided to residents. One out of four residents state staff are slow to respond when the emergency pendant is pushed. Staff indicate Resident 1 (R1) came back to the facility under the influence of marijuana after a visit with family and was observed face down in the resident's meal. Resident was immediately assessed once it was brought to staff's attention. Resident was determined to be without injury and coherent once awakened. During the visit, LPA observed three caregivers working along with two med techs. Based on interviews conducted, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, CONTINUED ON LIC 9099C DATED 01/08/2024
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
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 5
Control Number 22-AS-20240205143436
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: 01/08/2025
NARRATIVE
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meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/05/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240205143436

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: 61DATE:
01/08/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Chiquita MorrisTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility is not administering medications properly
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as medication administration records (MAR). Regarding the allegation that Facility is not administering medications properly, the investigation revealed the following: Physician order dated 09/20/2023 for Resident 1 (R1) indicates an order for Libre 2 Blood Glucose Sensor. Three out of three staff deny resident had a Libre 2 and state no awareness of resident requiring the device. Review of resident's MAR and notes show resident had missed Diabetes related injections due to facility not having glucose test strips. MAR indicates 13 missed medications during December 2023 with no notes indicating the reason for the missed medication. Based on record review, the preponderance of evidence standard has been met. CONTINUED ON LIC 9099C DATED 01/08/2024.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20240205143436
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: 01/08/2025
NARRATIVE
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Therefore the above allegation is 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 and a copy of this report was provided as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20240205143436
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: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2025
Section Cited
CCR
87464(f)(4)
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Basic services shall at a minimum include:
Personal assistance and care as needed by the resident.., with those activities of daily living such as assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This req is not met as evidenced by:
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Licensee to provide an in-service on medication administration and forward proof to LPA by POC due date.
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Based on record review, Licensee failed to ensure medication assistance was provided to resident. Resident missed multiple medications as well injections. This poses an immediate 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5