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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002915
Report Date: 07/28/2022
Date Signed: 07/28/2022 01:20:54 PM


Document Has Been Signed on 07/28/2022 01:20 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
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: 101DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Troy ByingtonTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. LPA met with Administrator (AD) Troy Byington who was present during the annual inspection. AD Byington has a current Administrators certificate that expires 11/5/23.

At 11:25 AM LPA Haley began the tour of the facility, During the today's visit there were 101 residents present. A screening station was observed at the entrance of the facility with temperature thermometer, and log book, observed at the reception desk.

The inspection began on the first floor. LPA Haley observed a large living room area with a TV and a bookshelf full of books. Several residents were observed in the living room area sitting down. There was a large dining room right next to the living room where more residents were observed sitting down at the dining tables. During the inspection LPA Haley checked random resident rooms and hot water temperatures. All resident rooms that were inspected were clean, well organized, and had all the necessary requirements: night stand, chair, lamps/lights and storage space. Bathroom water temperatures were recorded in the range of 105 - 113.9 degrees Fahrenheit. While inspecting the first floor, LPA Haley observed a storage room with plenty of PPE supplies: face mask, gowns, gloves, shoe covers, and wipes.

During the inspection LPA toured the memory care unit. There is a separate kitchen area where residents were observed eating lunch. Across from the kitchen in the memory care unit there's an activity room with a TV and a computer.

Around 11:43 AM LPA Haley inspected the 2nd floor. A medication room with a large medication cart was observed. In the medication room there was a drawer with first aid supplies. Both of the medication carts keep a first aid kit with all required elements, and there's an additional first aid kit on the wall across from the Med room. While on the 2nd floor LPA Haley inspected a few more rooms.


Continued on LIC 809 C Dated 7/28/22
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/28/2022
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Further, while still on the the 2nd floor LPA Haley observed an activity room where residents just finished a painting activity. A locked Housekeeping room with cleaning supplies and cleaning chemicals was observed.

On the 3rd level LPA Haley inspected a few more rooms, and all water temperatures recorded were in compliance with regulation guidelines. An activity room for residents on the third level was observed.

The main kitchen was very well organized. Food and refrigerator temperature logs were observed on the wall. LPA Haley observed a 2 day supply of perishable food items and a 7 day supply of non perishable food items.
Two charged and mounted fire extinguishers were observed. The main kitchen was noted to have new flooring recently installed.

The exterior portion of the facility was observed. All walkways were clear and free of debris. LPA Haley observed a shaded area with a table and chairs. Further, there were several benches in the grass area surrounded by large trees that provide plenty of shade. A gated area with tables and chairs was observed for the memory care residents.

Emergency drills are conducted monthly for a different shift. The fire alarm and sprinkler system is inspected by and outside company. The last inspection was conducted in June of 2022.

No bodies of water were observed during todays visit.

No deficiencies are being cited. An exit interview was conducted and a copy of the report was provided to Administrator Troy Byington.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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