306002954-6-2-2023-22-AS-SSAS-CSS2JR-20230613172647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002954
Report Date: 06/02/2023
Date Signed: 06/02/2023 03:43:53 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
10/03/2022 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221003131319

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: 83	DATE:	06/02/2023
		UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	Executive Director - Shannon Howell		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff sexually assaulted resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver the findings for the above allegation. LPA met with Executive Director (ED) Shannon Howell and stated the purpose of the visit. On 10/4/22, an initial 10-day visit was conducted.

The complaint was investigated by the Department. Findings are based upon this investigation which included record reviews and interviews.

It is alleged that facility staff sexually assaulted resident in care.

The investigation revealed that on September 13, 2022, resident (R1) reported that caregiver (S1) touched R1’s vaginal area in a sexual manner. It was later revealed that R1 discovered that S1 was making sexual advances with another resident, which led R1 to report the incidents to Executive Director.

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: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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-20221003131319

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: 06/02/2023

NARRATIVE

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Per Department interviews conducted with S1 regarding touching R1’s genital area, S1 stated “(I) told her not to tell anyone”. It was also revealed that the former management (Executive Director, Lead Nurse and Human Resource Department) were notified about S1’s history of inappropriate behavior, however, failed to report it and initiate any forms of disciplinary actions, and allowed S1 to continue to work at the facility.

Based on the information gathered during the investigation and review of documents obtained the allegation is SUBSTANTIATED.

See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with ED Howell. A copy of this report was explained, and appeal rights were provided during the visit.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20221003131319

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: 06/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/09/2023 Section Cited HSC 1569.50(a)(3)	1 2 3 4 5 6 7	H&S 1569.50 (a)(3) Conduct which is inimical to the health, morals, welfare or safety of either an individual in or receiving services from the facility or the people from the State of California. This regulation was not met as evidenced by:	1 2 3 4 5 6 7	Deficiency was CORRECTED. S1’s employment was immediately terminated on 9/18/22. Facility will conduct an in-service training to all the staff on the section cited and will provide LPA the proof of training conducted by 6/9/23.
	8 9 10 11 12 13 14	Based on Department investigation findings, it was determined that S1 engaged in sexual conduct with R1 constituting an act that is inimical to the health, safety and welfare of R1 receiving services from the facility. This violation poses an immediate safety risk to residents in care.	8 9 10 11 12 13 14
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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: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

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