306002954-10-20-2022-22-AS-LADS-CKUMH5-20221104093656

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002954
Report Date: 10/20/2022
Date Signed: 10/20/2022 03:51:29 PM

Substantiated

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
07/21/2022 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220721144127

FACILITY NAME:	BROOKDALE IRVINE		FACILITY NUMBER:	306002954
ADMINISTRATOR:	CARRIE GALLOWAY		FACILITY TYPE:	740
ADDRESS:	10 MARQUETTE		TELEPHONE:	(949) 854-3766
CITY:	IRVINE	STATE: CA	ZIP CODE:	92612
CAPACITY:	155	CENSUS: 92	DATE:	10/20/2022
		UNANNOUNCED	TIME BEGAN:	02:34 PM
MET WITH:	West Division Operations Specialist/Acting Executive Director (ED) Lilit Mnatsakanyan		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

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Staff is assisting residents while intoxicated

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with West Division Operations Specialist/Acting Executive Director (ED) Lilit Mnatsakanyan on behalf of AD Carrie Galloway and stated the purpose of this visit which was to deliver the final findings for the complaint received on 7/21/22 against this facility.

This agency has investigated the complaint alleging that staff is assisting residents while intoxicated. LPA De Perio conducted file reviews, and interviews and 6 out of the 9 interviews conducted, verified that staff member was intoxicated. 1 out of the 9 interviews that was conducted was with the staff who claimed to be intoxicated, and per interview, staff stated “I went to dinner and do what adults do, then I went to work” but declined to provide further information. Per interview with AD Galloway on 7/26/22, it was also stated that staff had made previous reports about this individual and expressed concerns about intoxication. Per reporting party, AD Galloway stated “I already wrote her up”. Upon LPA De Perio requesting for a copy of the “write-up”, there were no records indicated nor found that one was ever created.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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-20220721144127

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 IRVINE	FACILITY NUMBER: 306002954
	VISIT DATE: 10/20/2022

NARRATIVE

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In the Brookdale Irvine Associate Handbook, section “Associate Responsibilities” on page 41, it states: “The list below, therefore, is not all encompassing; it is intended to provide examples of misconduct that are considered inappropriate and for which an associate may be terminated, even for a first offense...Reporting to work intoxicated or under the influence of alcohol or any drugs or controlled substances that may impact your ability to perform your job or otherwise pose safety concerns."

On Page 57 titled “Drug-Free Workplace”, it states: “While on the job, no associate may use, possess, distribute, sell, or be under the influence of alcohol or illegal, non-prescribed, or over-the-counter drugs that may impact an associate’s ability to perform their job or otherwise pose safety concerns.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

For today's visit citations were issued per Title 22 Division 6 of the California Code of Regulations.
See LIC9099-D.

LPA De Perio conducted an exit interview with AD Mnatsakanyan and a copy of this report, regulation discussed and specified on LIC9099-D and Appeal Rights were provided to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20220721144127

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 IRVINE	FACILITY NUMBER: 306002954
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/27/2022 Section Cited CCR 87411(a)(f)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall...be competent to provide the services necessary... (f) All personnel...shall be...physically and mentally capable... This requirement is not met as evidence by:	1 2 3 4 5 6 7	As Plan of Correction (POC), administrator will provide training to staff about the regulation cited and will submit proof to assigned LPA and CCL on or by 10/27/22.
	8 9 10 11 12 13 14	Based on observation, interviews and record review, facility failed to ensure that personnel is competent to provide services necessary...and that personnel is physically and mentally capable of performing assigned tasks. This poses an immediate threat on the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC9099 (FAS) - (06/04)

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