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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002954
Report Date: 06/14/2023
Date Signed: 06/14/2023 02:56:32 PM


Document Has Been Signed on 06/14/2023 02:56 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: 80DATE:
06/14/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Executive Director (ED) Shannon HowellTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 06/02/2023. LPA De Perio explained reason for visit and was greeted by Executive Director (ED) Shannon Howell.

*Deficiency cited under Health and Safety Code 1569.50 (a)(3) has been CLEARED. ED Howell conducted an in-service training to all the staff on the section cited, obtained signatures of the staff present, and provided proof of training to LPA.

For this visit, no citations were issues.

An exit interview was conducted with ED Howell. A copy of this report was provided and explained.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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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