<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002915
Report Date: 08/17/2022
Date Signed: 08/17/2022 03:25:50 PM


Document Has Been Signed on 08/17/2022 03:25 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: 103DATE:
08/17/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Troy Byington, Mink MedinaTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Manager (LPM) Armando Lucero and Licensing Program Analyst (LPA) Sean Haddad conducted an informal conference via Microsoft Teams with Administrator (AD) Troy Byington and Wellness Director (WD) Mink Medina.

The purpose of the meeting was to follow up on the pending eviction of Resident #1 (R1) who has not paid rent for multiple months and is not cooperating with the facility’s attempts to reassess R1 to ensure R1’s needs are met. The facility is working with the Department, Adult Protective Services (APS), the Long-Term Care Ombudsman (LTCO), and other stakeholders to reassess R1 and ensure R1 continues to receive the care and supervision they need while the eviction is currently pending.

During the meeting, the following items were discussed:
  • R1’s medical history and condition.
  • The next steps to be taken in assessing R1 and ensuring R1 continues to receive the care and supervision they need.
  • Additional time to complete these steps before the eviction is completed.

An exit interview was conducted. This report will be emailed and an electronic email read receipt confirms receipt of the report. Facility representative agrees to sign the report and email it back to LPA.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1