306002915-12-27-2024-22-AS-SHAN-DCCTPC-20241227135408

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002915
Report Date: 12/27/2024
Date Signed: 12/27/2024 01:54:24 PM

Document Has Been Signed on 12/27/2024 01:54 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 ANAHEIM		FACILITY NUMBER:	306002915
ADMINISTRATOR/ DIRECTOR:	TROY BYINGTON		FACILITY TYPE:	740
ADDRESS:	200 N DALE ST		TELEPHONE:	(714) 761-5771
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY: 140	TOTAL ENROLLED CHILDREN: 0	CENSUS: 110	DATE:	12/27/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:45 PM
MET WITH:			TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced case management visit. LPA was greeted and granted entry into the facility by concierge and later met with Executive Director (ED) Troy Byington.

The purpose of the visit is to follow-up on an incident report that was sent by this facility to Community Care Licensing; the incident report stated resident (R1) contacted 911 emergency services due to sever knee pain which led to R1 taken to Saint Joseph Hospital and later determined that R 1 had hip fracture. It was later determined that R1 responsible party who contacted 911 as he was in the facility. Also, the initial incident happen earlier that day when R1 had slipped out of wheelchair and fell and called for help.

LPA reviewed resident’s file and LIC-602 (Physician’s Report) and observed that R1 is nonambulatory.

Based on today’s visit, deficiencies cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

Alisa Ortiz	TELEPHONE: (714) 703-2855
Samer Haddadin	TELEPHONE: (714) 790-2096
	DATE: 12/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024

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 12/27/2024 01:54 PM - 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: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervisio.
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 12/27/2024
	Plan of Correction
1 2 3 4	Licensee stated they will create fall prevention policy and train supervisory staff on the policy and submit proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Alisa Ortiz	TELEPHONE: (714) 703-2855
Samer Haddadin	TELEPHONE: (714) 790-2096
	DATE: 12/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024

LIC809 (FAS) - (06/04)

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