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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002954
Report Date: 05/16/2024
Date Signed: 05/16/2024 05:12:02 PM


Document Has Been Signed on 05/16/2024 05:12 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: 86DATE:
05/16/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Executive Director Specialist- Shannon Howell TIME COMPLETED:
05:15 PM
NARRATIVE
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An informal conference was held on this date at the Orange County Adult and Senior Care Regional Office, in Orange, California. The information meeting purpose and process was explained to Executive Director Specialist (ED) Shannon Howell.

Present during the meeting were Licensing Program Manager (LPM), Sheila Santos, Licensing Program Analyst (LPA) Celine De Perio, and the new Executive Director Specialist, Shannon Howell.

LPM Santos reviewed the following items with Executive Director Specialist:

  • Complaint: 22-AS-20221003131319 with allegation of facility staff sexually assaulted resident in care. Substantiated on June 2, 2023.
  • Importance of taking immediate action regarding any incidents of reported inappropriate behaviors towards staff and residents.
  • Quality assurance procedure for licensee and administrator verifying that established procedures and policies are followed.

The following plan was put in place:

1. The licensee will provide the internal investigation reports regarding previous Administrator and previous staff (S1).



2. The licensee will provide the facility procedure to safely store personnel records to prevent them to be compromised or lost.

During the office meeting additional citations were issued by LPA De Perio.

An exit interview was conducted. A copy of this report was read and provided to ED Shannon Howell. Appeal rights explained and provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 05/16/2024 05:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: BROOKDALE IRVINE
FACILITY NUMBER: 306002954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2024
Section Cited
CCR
87205(a)

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87205 Accountability of Licensee Governing Body
(a) The licensee, whether an individual or other entity, shall exercise general supervision...and the welfare of the individuals it serves.
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As a plan of correction (POC) ED will provide understanding of the regulation cited, and will formulate a training to all staff on the importance of not coming to work intoxicated. ED will provide proof to assigned LPA on or by May 30, 2024.
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This requirement is not met as evidence by:
Based on the Department’s interviews conducted, during the duration of S1’s employment, despite the complaints of inappropriate behaviors and intoxication, knowing about the sexual harassment allegations, the former management failed to exercise general supervision over the affairs of the licensed facility, initiate any forms of disciplinary action, and allowed for S1 to continue working at the facility.
This poses a potential health and safety risk to residents in care.
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Type B
05/30/2024
Section Cited
CCR87411(f)

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87411 Personnel Requirements
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.
This requirement is not met as evidence by:
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As a plan of correction (POC), S1 was terminated on September 17, 2023.
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Based on the Department’s interviews conducted, during the duration of S1’s employment, S1 was reported of coming into work intoxicated, and facility failed to ensure S1 was physically and mentally capable of providing care to residents.
This poses a potential health and safety risk to residents in care.
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Deficiency cleared.
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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/16/2024 05:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: BROOKDALE IRVINE
FACILITY NUMBER: 306002954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2024
Section Cited
CCR
87405(a)

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87405 Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator…
This requirement is not met as evidence by:
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As a plan of correction (POC) facility has hired a new administrator
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Based on the Department’s interviews conducted, during the duration of S1’s employment, despite the complaints of inappropriate behaviors and intoxication, management failed to initiate any forms of disciplinary action. Facility failed to perform the duties of a qualified administrator. This poses a potential health and safety risk to residents in care
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Deficiency cleared

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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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
LIC809 (FAS) - (06/04)
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