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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002954
Report Date: 01/19/2023
Date Signed: 01/19/2023 12:54:31 PM

Unfounded


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
05/06/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220506152646
FACILITY NAME:BROOKDALE IRVINEFACILITY NUMBER:
306002954
ADMINISTRATOR:CARRIE GALLOWAYFACILITY TYPE:
740
ADDRESS:10 MARQUETTETELEPHONE:
(949) 854-3766
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY:155CENSUS: 82DATE:
01/19/2023
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Lilit MnatsakanyanTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Staff are not properly trained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, reviewed staff training records and interviewed staff. Regarding the allegation that staff are not properly trained, the investigation revealed the following: Five out of five staff training records reviewed contained proof of current staff training. Training included but not limited to: Dementia training, Alzheimer's Disease, Postural Supports, Restricted Conditions and Personal Rights. Five out of five staff interviewed stated receiving training from the facility. Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
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
05/06/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220506152646

FACILITY NAME:BROOKDALE IRVINEFACILITY NUMBER:
306002954
ADMINISTRATOR:CARRIE GALLOWAYFACILITY TYPE:
740
ADDRESS:10 MARQUETTETELEPHONE:
(949) 854-3766
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY:155CENSUS: 82DATE:
01/19/2023
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Lilit MnakanyanTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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9
Staff do not follow physician's orders.
Staff do not respond to residents' call lights in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, pushed call buttons, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report and pendant call logs. Regarding the allegations that staff do not follow physician's orders and staff do not respond to residents' call lights in a timely manner, the investigation revealed the following: Resident 1 (R1) has conflicting physician orders regarding alcohol consumption. Two orders are dated 02/04/2022. One order states limited alcohol consumption, no more than 2 drinks per day and one order states no alcohol to be consumed. Physician report dated 03/13/2022 indicates no alcohol consumption and Order Review Report dated 12/22/2022 indicates physician order stating no alcohol dated 02/05/2022. R1 states being served one drink daily at happy hour. Five out of six witnesses to facility happy hour stated R1 was served alcohol at happy hour. LPA observed the dietary restriction board in the kitchen outlining resident's dietary restrictions. CONT ON LIC 9099C DATED 01/19/2022
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20220506152646
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: 01/19/2023
NARRATIVE
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R2 is on a nectar thick diet which facility has documented resident refusal. During two different visits, LPA pulled the emergency cord in 5 rooms. LPA received four staff responses within 20 minutes and no response in one pull. Review of pendant pull/ emergency response times for 05/01/2022-05/08/2022 indicated 40 response times between 23 minutes and one hour. Administrator stated expected response times are within 15 minutes. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility along with appeal rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 22-AS-20220506152646
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: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited
CCR
87464(f)(1)
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Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
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Licensee to provide a statement of understanding regrding the regulation and forward to LPA by POC due date.
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Based on record review and observation, Licensee failed to ensure care and supervision was provided to residents. Emergency pendant response times ranged between 23 minutes and 1 hour for the week of 05/01/2022-05/08/2022 and LPA received no staff response in 1 out of 5 pulls. This poses an immediate health and safety risk.
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Type B
02/02/2023
Section Cited
CCR
87464(f)(2)
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Basic services shall at a minimum include: Safe and healthful living accommodations and services... This requirement is not being met as evidenced by:


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Licensee to provide re-training to staff on following physician orders and forward proof to LPA by POC date.
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Based on record review and interviews, Licensee failed to ensure R1 was provided safe and healthful accommodations. Resident was served alcohol even though physician order indicates no alcohol for resident. This poses a potential health and safety risk to residents in care,
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4