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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002915
Report Date: 10/12/2023
Date Signed: 10/12/2023 04:18:27 PM


Document Has Been Signed on 10/12/2023 04:18 PM - It Cannot Be Edited

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 ANAHEIMFACILITY NUMBER:
306002915
ADMINISTRATOR:TROY BYINGTONFACILITY TYPE:
740
ADDRESS:200 N DALE STTELEPHONE:
(714) 761-5771
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:140CENSUS: 103DATE:
10/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Mink Medina, Health and Wellness DirectorTIME COMPLETED:
04:35 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) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA met with the Health and Wellness Director Mink Medina and explained the reason for the visit. During the complaint investigation for complaint # 22-AS-20200915080631, LPA observed that the facility did not have the See Something, Say Something poster (PUB 475) posted in the main entrance way of the facility. LPA issued an advisory note, technical assistance for CCR (California Code of Regulation) 87468(c)(2)(A). LPA consulted with the Health and Wellness Director concerning CCR 87468(c)(2)(A) and reporting requirements. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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