306002954-12-1-2022-22-AS-SSAS-CM432P-20221213165217

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002954
Report Date: 12/01/2022
Date Signed: 12/01/2022 04:21:04 PM

Unsubstantiated

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
11/29/2022 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221129121238

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:	12/01/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Lilit Mnatsakanyan, Operations Specialist Phat Nguyen, Executive Director Stacey Handy, Health and Wellness Director Joshua Oliver, Business Office Manager		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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1/ Facility staff is under the influence when providing care to residents.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit to the facility for the purpose of investigating the allegation listed above. LPA was greeted and granted entry by Operations Specialist Lilit Mnatsakanyan and Executive Director Phat Nguyen after being screened and temperature checked for COVID-19. LPA listed the allegation being investigated.

LPA requested and obtained select staff records, the current resident roster, the updated Personnel Report LIC500 as well as a copy of the Associate Handbook being provided to new employees upon hire.

LPA additionally conducted interviews with Operations Specialist, Executive Director, Business Operations Manager, Health and Wellness Director, Programs Director, Programs Assistant along with one caregiver and two Med Tech staff members on duty on the day of the visit. Resident R1 was also interviewed during the visit.

CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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-20221129121238

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: 12/01/2022

NARRATIVE

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CONTINUED FROM FORM LIC9099

The majority of individuals intervieedw had either no knowledge or not directly witnessed any event or circumstances that would corroborate the allegation investigated.

Documentation confirming a staff training session focused on the Associate Handbook and its clauses regarding Brookdale Irvine being a drug-free environment were provided to LPA during the visit. Management staff also indicates that random checks on the evening shift are conducted multiple times a week and have not provided any evidence of the alleged behavior happening at the facility. LPA was also able to tour the physical plant during the course of the complaint investigation.

Based on records reviewed, observation made and interviews conducted, the allegation listed above is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was provided and a copy of this report was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC9099 (FAS) - (06/04)

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