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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002954
Report Date: 02/25/2022
Date Signed: 02/25/2022 01:41:35 PM


Document Has Been Signed on 02/25/2022 01:41 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 IRVINEFACILITY NUMBER:
306002954
ADMINISTRATOR:CARRIE GALLOWAYFACILITY TYPE:
740
ADDRESS:10 MARQUETTETELEPHONE:
(949) 854-3766
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY:155CENSUS: 114DATE:
02/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Carrie GallowayTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on a death report submitted to Community Care Licensing on 02/24/2022. LPA was greeted and granted entry into the facility by Executive Director Carrie Galloway and explained the reason for the visit.

Death report dated 02/23/2022 indicated Resident 1(R1) was found outside the resident's room around 1 AM on 02/22/2022 after pushing the pendant for assistance. R1 was confused and disoriented. R1 was assessed and had low oxygen saturation. R1 agreed for medical intervention and 911 was called. Paramedics responded and R1 became unresponsive on the stretcher. CPR was initially started but then stopped due to resident having a "Do not resuscitate" on file. Resident was pronounced dead at 2:19 AM.

During the visit, LPA toured the facility and interviewed Executive Director as well as reviewed and obtained pertinent documentation such as physician report and facility notes. Per physician report dated 09/11/2019, R1 has a diagnosis of Type 2 Diabetes, Essential Hypertension, Hyperlipidemia, Unspecified Depressive Disorder, Benign Neoplasm of Prostate and Benign Prostatic Hyperplasia.

Facility to provide a copy of death certificate to LPA upon receipt.





Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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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