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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001000
Report Date: 12/01/2021
Date Signed: 12/01/2021 12:47:40 PM



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
11/23/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20211123154819
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
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Daniel LinesTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility charging fees and rent for services not provided.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kimberly Lyman and Kevin Saborit-Guasch conducted an unannounced complaint visit to initiate investigation on the above allegation. LPAs were greeted and granted entry into the facility by Executive Director Daniel Lines and explained the reason for the visit.

During the course of the investigation, LPAs interviewed Executive Director (ED) as well as reviewed and obtained pertinent documentation such as billing records and credit statements. Regarding the allegation that facility charging fees and rent for services not provided, the investigation revealed the following: Resident 1 (R1) was a resident at the facility from 09/05/ 2021- 09/28/2021 as respite. R1 transitioned to a regular resident from 09/29/2021-10/31/2021. Upon review of billing, LPAs observed a discrepancy on the statement. ED stated R1's total amount owed was $210 referencing personal solutions. Review of bill indicated R1 had paid for $134 out of $210 leaving a balance due of $76 only. There is nothing in writing indicating resident owes $210 only verbal notification from ED and current invoice indicates R1 owes $1594.00. ED states R1 has been credited CONTINUED ON LIC 9099C DATED 12/01/2021.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20211123154819
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: 12/01/2021
NARRATIVE
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all but $210 and the bill does not reflect that. ED provided a credit statement indicating the credits have been applied. The preponderance of evidence standard has been met, 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 with ED and a copy of this report was provided as well as appeal rights.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 22-AS-20211123154819
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: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2021
Section Cited
CCR
87468.2(a(8)
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In addition to the rights listed in Section...., residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To be free from neglect, financial exploitation... This requirement is not being met as evidenced by:
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Licensee provided a credit to R1's account during the visit and will forward notification of credit to R1. CLEARED DURING VISIT.
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Based on record review, Licensee failed to ensure R1 was free from financial exploitation. Upon record review, LPA observed a discrepancy on R1's bill resulting in R1 being overcharged. This poses a potential 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3