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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001000
Report Date: 12/01/2021
Date Signed: 12/01/2021 12:51:01 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: 56DATE:
12/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Daniel LinesTIME COMPLETED:
01:10 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Kevin Saborit-Guasch conducted an unannounced case management visit to follow up on an incident report submitted to Community Care Licensing on 11/22/2021. LPAs were greeted and granted entry into the facility by Executive Director Daniel Lines and explained the reason for the visit.

Incident report dated 11/22/2021 indicated that Resident 1(R1) was discovered by a neighbor right outside the facility gate with the resident's dog. Authorities were notified and resident was redirected back into the facility. R1 was put on hourly checks as well as a caregiver outside the resident's room overnight.

During the visit, LPAs observed R1's room as well as the exit path. LPAs reviewed R1's physician report dated 10/12/2021 indicating R1 has a diagnosis of Mild Cognitive Impairment. R1 was moved by family into a memory care unit on 11/24/2021 with no adverse affects. Executive Director states R1 had exhibited behaviors and a gradual decline.



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: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
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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