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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002954
Report Date: 03/16/2022
Date Signed: 03/16/2022 12:26:34 PM


Document Has Been Signed on 03/16/2022 12:26 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: 109DATE:
03/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carrie GallowayTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports submitted to Community Care Licensing. LPA was greeted and granted entry into the facility by Executive Director Carrie Galloway and explained the reason for the visit.

Incident report dated 03/03/2022 indicated Resident 1 (R1) was observed in the dining room choking by dietary staff. Facility LVN responded at 11:50 AM and immediately started the Heimlich Maneuver on resident. Staff called 911 at 11:53 AM while tending to resident. Staff moved the resident who was in a wheelchair to an adjacent room to continue the Heimlich Maneuver. Paramedics responded at 12:01 and immediately started life saving procedures. Resident was transported to Hoag Hospital at 12:12 PM where resident subsequently passed away on 03/10/2022. Per physician report dated 09/13/2021, R1 is able to self feed and is not on a special diet. Staff interviewed confirm while resident has left sided paralysis, the resident has no swallowing issues. There have been no other choking incidents with the resident.

Incident report dated 03/06/2022 indicated facility received a phone call from Mason Regional Park Ranger stating R2 and R3 were lost at the park and R3 was in need of medical attention due to a fall at the park. Park ranger returned the residents to the facility and R3 was sent out for medical attention due to back pain. R3 returned the next day with no new orders. Mason Park is approximately one mile away. Per physician orders, both residents are unable to leave the facility unassisted. Facility investigation revealed residents may have left through a back door which had been propped open. Facility has a list of residents unable to leave the facility unassisted at the front desk. LPA observed front desk staff confirming residents can leave the facility while checking in. Facility has secured all doors except the front door to funnel everyone in and out of front door. Both residents have been fitted with wander guards and advised both are unable to leave facility. R3 previously had a wander guard but removed it. Facility is doing daily wander guard checks and documenting. LPA spoke with both residents during the visit and both appear safe and well taken care of. CONT ON LIC 809C DATED 03/16/2022.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/16/2022
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R2 is diagnosed with Mild Cognitive Impairment and R3 is diagnosed with Dementia.
Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC809 (FAS) - (06/04)
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