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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002954
Report Date: 09/11/2023
Date Signed: 09/11/2023 03:34:51 PM


Document Has Been Signed on 09/11/2023 03:34 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
ORANGE COUNTY RO, 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: 77DATE:
09/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:07 PM
MET WITH:Shannon Howell-Executive DirectorTIME COMPLETED:
03:50 PM
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On this day Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced visit to deliver an amended report dated 07/26/23 in conjunction with complaint 22-AS-20230724102229. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Shannon Howell.


An exit interview was conducted with ED Howell and a copy of this report was provided at the time of exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023
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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