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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002915
Report Date: 09/22/2021
Date Signed: 09/22/2021 04:29:38 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 ANAHEIMFACILITY NUMBER:
306002915
ADMINISTRATOR:TROY BYINGTONFACILITY TYPE:
740
ADDRESS:200 N DALE STTELEPHONE:
(714) 761-5771
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:140CENSUS: 89DATE:
09/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:23 PM
MET WITH:Troy ByingtonTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to follow up on an SIR (special incident report) received on 9/21/2021, SIR was dated 9/13/2021. LPA was screened for Covid-19 symptoms and granted entry. LPA met with Administrator Troy Byington and Health & Wellness Director Mink Medina. LPA explained the reason for the visit. SIR reported that resident 1 (R1) had requested items to harm themself. Facility staff called 911. R1 was assessed by paramedics and it was determined that R1 was not in distress and left her at the facility. Possible dangerous items were removed from R1's room and facility staff monitored R1 throughout the night. The next day on 9/14/21 R1 was assessed by a third party nurse practitioner. Family was notified 9/13/21 about the incident. Primary Care Physician (PCP) was notified on 9/13/21. R1 was seen on 9/15/21 by the nurse practitioner and seen by the behavioral health nurse on 9/17/21. R1 has not experienced a change in condition since her admission. Both the behavioral health nurse and nurse practitioner reported that R1 is doing well and does not pose a threat to themself. LPA interviewed R1. R1 answered all of LPA's questions. LPA observed that R1 was aware of the date and time and reported they were feeling fine and had no issues or concerns. The facility has reported the incident to the Agency and notified the PCP and family of R1. R1 was assessed by medical professionals and is being monitored by facility staff. R1 will have continued visits with the nurse practitioner and behavioral health nurse. Based on the information provided and documents reviewed, no deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of this report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
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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