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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002915
Report Date: 08/02/2023
Date Signed: 08/02/2023 11:08:08 AM


Document Has Been Signed on 08/02/2023 11:08 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 ANAHEIMFACILITY NUMBER:
306002915
ADMINISTRATOR:TROY BYINGTONFACILITY TYPE:
740
ADDRESS:200 N DALE STTELEPHONE:
(714) 761-5771
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:140CENSUS: 98DATE:
08/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Troy Byington, Executive DirectorTIME COMPLETED:
11:30 AM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of following up on a Report of Suspected Elder Abuse form (SOC341) submitted by the facility on July 31, 2023. LPA was greeted and granted entry by Executive Director (ED) Troy Byington after introducing himself and stating the purpose of the visit.

LPA conducted an interview with ED regarding the circumstances of the reported incident. Anaheim Police Department came and interviewed residents R1 and R2 on July 31, 2023. The corresponding police report is referenced 23-11281.

LPA accompanied with ED conducted a tour of the physical plant and visited R1 & R2 in their shared unit on the facility's second floor. Both residents appear well kempt and taken care of, with no apparent signs of distress observed. No other health and safety concerns noted at this time.

LPA requested and obtained the facility's current census, employee roster (LIC500) as well as face sheets and most recent physician reports for residents R1 and R2.

No deficiencies cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
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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