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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002915
Report Date: 10/02/2024
Date Signed: 10/02/2024 04:24:25 PM


Document Has Been Signed on 10/02/2024 04:24 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
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: 109DATE:
10/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Executive Director- Troy ByingtonTIME COMPLETED:
04:35 PM
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On October 2, 2024, at 12:30pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced Case Management Visit to follow-up on a death report received from the facility. LPA Kim was greeted and granted entry by staff. LPA explained the purpose of the visit to Executive Director (ED) Troy Byington. During today’s visit, LPA conducted a health and safety check, and there were no imminent health/safety concerns observed. Facility maintained at a comfortable temperature for the residents in care. A two-day supply of perishable and seven-day supply of non-perishable food were observed to be sufficient at the time of inspection. LPA obtained LIC 500, LIC 9020, and R1’s records which includes the Physician’s Report, Admission’s Agreement, Emergency Information, Consent Forms, and Appraisal and Needs/Service Plan. LPA interviewed ED Troy Byington.

No deficiencies were observed during this visit.

An exit interview was conducted, and a copy of this report was provided to the Executive Director Troy Byington.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward KimTELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024
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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