306002915-10-18-2021-22-AS-LADS-C87LD2-20211027083911

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002915
Report Date: 10/18/2021
Date Signed: 10/18/2021 04:15:41 PM

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
10/15/2021 and conducted by Evaluator Joseph Alejandre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20211015095943

FACILITY NAME:	BROOKDALE ANAHEIM		FACILITY NUMBER:	306002915
ADMINISTRATOR:	TROY BYINGTON		FACILITY TYPE:	740
ADDRESS:	200 N DALE ST		TELEPHONE:	(714) 761-5771
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	140	CENSUS: 90	DATE:	10/18/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Troy Byington, Mink Medina		TIME COMPLETED:	04:31 PM

ALLEGATION(S):

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The staff did not provide adequate supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA was greeted and granted entry by staff. LPA met with facility Administrator. LPA explained the reason for the visit. LPA interviewed Administrator and staff. LPA has already interviewed the responsible party and the complainant. The investigation revealed the following; on 10/14/2021 the resident (R1) suffered an unwitnessed fall. Staff discovered R1 at 7:15 am and assessed R1 and called 911. At 7:42 am Resident was transported to the Emergency Room and treated. The resident was treated for a “closed head injury” and released the same day. LPA verified with the hospital social worker that the resident was treated and released the same day. Resident returned to facility at 9:15 pm on 10/14/2021. Staff reported that all residents are checked every hour in memory care and the staff constantly rotate and are checking all residents even when they are in their rooms. LPA reviewed the facility work schedule. Facility had scheduled 2 caregivers and 1 med-tech for memory care at the time the resident was discovered. 11 residents currently resident in memory. R1 is not receiving one on one care through a third party provider. The facility has enough caregivers to provide care and supervision for the residents in memory care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20211015095943

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: 10/18/2021

NARRATIVE

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None of the parties interviewed could corroborate the allegation. The preponderance of evidence standard has not been met based the evidence gathered, therefore the allegation, the staff did not provide adequate supervision, is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and the Administrator was provided a copy of the report.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021

LIC9099 (FAS) - (06/04)

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