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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002915
Report Date: 08/19/2022
Date Signed: 08/19/2022 01:22:35 PM


Document Has Been Signed on 08/19/2022 01:22 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:
08/19/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Mink MedinaTIME COMPLETED:
01:37 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
This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check on 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. LPA was joined by Witness #1 (W1), a social worker from the Orange County Social Services Agency, Witness #2 (W2), the assigned Long Term Care Ombudsman, and Witnesses #3 (W3) and #4 (W4), officers from the Orange County Sheriff’s Department. LPA met with Wellness Director (WD) Mink Medina and explained the purpose of the inspection.

During the inspection, LPA conducted a health and safety check on R1, interviewed R1 and WD, and discussed the following items with W1, W2, W3, W4, and WD:
  • 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.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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