306002954-8-8-2022-22-AS-CDPO-CH4R28-20220808123755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002954
Report Date: 08/08/2022
Date Signed: 08/08/2022 12:38:03 PM

Document Has Been Signed on 08/08/2022 12:38 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 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: 100	DATE:	08/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Facility Administrator-Carrie Galloway		TIME COMPLETED:	12:55 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 Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio was greeted by receptionist on duty who checked temperature prior to entering lobby waiting area. During the visit, LPA De Perio was accompanied by facility administrator (AD) Carrie Galloway. As of 8/8/22, there are no active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted throughout the facility. LPA observed the Administrator's Certificate for Carrie Galloway which expires on 10/28/2023. LPA De Perio toured the interior and exterior portions of the facility with AD Galloway. During this visit, there are a total of 24 staff members on duty. The facility is a three level structure and is licensed for 155 non-ambulatory residents, of which 15 may be on hospice and 0 may be bedridden. Currently, there are a total census of 100 residents in care. LPA De Perio initiated random bedroom checks, of which bedrooms were observed to have furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Water temperature in restrooms were measured to be at 113.4 degrees Fahrenheit. Smoke and carbon monoxide detectors were operational and most recent fire inspection took place on 11/12/2021, of which inspection was passed. Auditory alarms and wander guard functions were also tested and observed to be operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. LPA De Perio also tested pull cords in resident bathrooms, and observed to be operational.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022

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 IRVINE	FACILITY NUMBER: 306002954
	VISIT DATE: 08/08/2022

NARRATIVE

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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Facility had back-up emergency food and water supply. LPA De Perio reviewed the most recent audit for the quarterly dietitian visit, which took place on 4/13/22. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and located in multiple areas of the facility. LPA De Perio observed exit stairwells and each floor had an evacuation chair. Facility does not have delayed egress doors.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the main entrance behind the front desk.

LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the medication room, closet, and office. Medications were locked and inaccessible to residents in care. Toxins were also observed to be locked and inaccessible to residents.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Galloway. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio advised AD Galloway to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Galloway and a copy of this report was 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: 08/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022

LIC809 (FAS) - (06/04)

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