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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002915
Report Date: 12/21/2023
Date Signed: 12/21/2023 01:05:14 PM

Substantiated


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
11/20/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20231120164159
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: 110DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Troy Byington - Executive Director TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Licensee does not ensure facility is free from roaches.
INVESTIGATION FINDINGS:
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On this Day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Executive Director Troy Byington explained the reason for the visit.

The Department received a complaint on 11/20/2023 and LPA Mendivil conducted the initial 10 day visit on 11/30/2023. During the visit LPA Mendivil interviewed staff and residents. LPA Mendivil obtained copies of pertinent documents such as pest control invoice, resident roster and pest sighting/evidence log. Regarding the allegation Licensee does not ensure facility is free from roaches, the investigation revealed the following:

Per review of the pest sighting/evidence log there was a presence of pest on 11/15/2023, 11/24/2023 and 11/25/2023. During the visit on 11/30/2023 LPA Mendivil observed a small cockroach in an unoccupied room’s bathroom.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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-20231120164159
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 ANAHEIM
FACILITY NUMBER: 306002915
VISIT DATE: 12/21/2023
NARRATIVE
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 Though there is a presence of cockroaches the facility has a contract with a pest control company that visits the facility a minimum of 1 time every 10 days and also as needed. In the pest control visits the company outlines services provided on that given day and also if they noted any pest activity. Per the invoice provided on 11/20/2023 no rodent or insect activity was noted during the inspection and/or service.

Therefore based on the preponderance of evidence through records reviewed and observations the allegation licensee does not ensure facility is free from roaches is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.


The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20231120164159
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 ANAHEIM
FACILITY NUMBER: 306002915
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2023
Section Cited
CCR
87303(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Executive Director stated facility has an ongoing contract with Ecolab to continue pest control throughout the facility. Executive Director to provide follow up visit information on POC due date.
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This requirement was not met as evidence by facility resident and staff have noted roach sightings on 11/15/2023, 11/24/2023 and 11/25/2023. This poses a potential health risk to persons 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) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
11/20/2023 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231120164159

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: 110DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Troy Byington - Executive Director TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff disclosed resident information to a third party without authorization.
INVESTIGATION FINDINGS:
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On this Day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Executive Director Troy Byington explained the reason for the visit.

The Department received a complaint on 11/20/2023 and LPA Mendivil conducted the initial 10 day visit on 11/30/2023. During the visit LPA Mendivil interviewed staff and residents. Regarding the allegation staff disclosed resident information to a third party without authorization, the investigation revealed the following:

It was alleged by a witness the facility provided personal health and insurance information to a medical provider. Per interviews with 3 out of 3 staff they indicated they do not give information regarding residents to any third party unless there is authorization. Based on interview with Executive Director Troy Byington, he stated that all residents are provided with a list of providers and if they are interested they would have to reach out to the providers themselves.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20231120164159
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 ANAHEIM
FACILITY NUMBER: 306002915
VISIT DATE: 12/21/2023
NARRATIVE
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Based on interviews with 4 out of 4 residents indicated they have not had their information given to a third party. Based on interviews with 4 out of 4 residents indicate they have not been solicited by any company with unauthorized information.

Therefore based on the preponderance of evidence through interviews and records reviewed the allegation staff disclosed resident information to a third party without authorization is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint.

No deficiencies cited.
An exit interview was conducted and a copy of this report provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5