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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002915
Report Date: 09/24/2024
Date Signed: 09/24/2024 10:15:23 AM


Document Has Been Signed on 09/24/2024 10:15 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: 111DATE:
09/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Executive Director, Troy ByingtonTIME COMPLETED:
10:45 AM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to follow up on documentation paperwork for a three day eviction notice issued on 9/23/2024. LPA met with Executive Director Troy Byington. LPA obtained the following requested documents for Resident 1 (R1):
  • Residents Admission Agreement
  • Resident's pre appraisal
  • Most recent physician's report
  • Caregiver progress notes/ Charting notes
  • copy of medication list
  • Copy of updated personal service plan
  • copy of care plan



LPA did not obtain any copies of pertinent incident reports, per Executive Director stated R1 did not have any on file. LPA did not obtain a copy of recent appraisal because one was not recently done but Facility provided copies of updated Care plan and Personal service plan.

At today's visit LPA Tirre is issuing a citation for facility not providing documents when requested on 9/23/24. The following citation will be issued on D page.

LPA conducted exit interview with Executive Director Byington. LPA provided copy of report along with 809 D-Page and LIC 811 confidential names list.


SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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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Document Has Been Signed on 09/24/2024 10:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: BROOKDALE ANAHEIM
FACILITY NUMBER: 306002915

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2024
Section Cited
CCR
87506(d)

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87506 Resident Records. d- All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.
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Plan of correction is for licensee to review regulation and provide written statement understanding regulation by POC date.
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This requirement was not met as evidenced by Facility was unable to provide copies of resident records to Licensing in timely manner as originally requested. facility did provide copies however afer requested time frame. 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: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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