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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002954
Report Date: 09/13/2024
Date Signed: 09/13/2024 01:16:18 PM


Document Has Been Signed on 09/13/2024 01:16 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: 119DATE:
09/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Sharin Belanger-Business Office ManagerTIME COMPLETED:
01:35 PM
NARRATIVE
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 On this day, Licensing Program Analysts (LPA) Alvaro Ramirez, Jr. made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry to facility by Business Office Manager (BOM) Sharin Belanger.

LPA Ramirez toured the interior and exterior portions of the facility with BOM Belanger. During this visit, there are a total of 21 staff members on duty. The facility is a three level structure and is licensed for 155 non-ambulatory residents, of which 15 may be on hospice and 0 may be bedridden. Currently, there are a total census of 119 residents in care. LPA Ramirez initiated random bedroom checks, of which bedrooms were observed to have furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Water temperature in restrooms were measured to be between 111.0-115.8 degrees Fahrenheit.

Smoke and carbon monoxide detectors were operational and most recent fire inspection took place on August 06, 2024, of which inspection was passed. Auditory alarms and wander guard functions were also tested and observed to be operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. LPA Ramirez also tested pull cords in resident bathrooms, and observed to be operational.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Facility had back-up emergency food and water supply. LPA toured the kitchen and observed the weekly food menu. LPA also observed handouts for Resident Programs Daily Events which included express manicure, Jeopardy Wii and Spanish 101. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and located in multiple areas of the facility. LPA observed exit stairwells and each floor had an evacuation chair. Facility does not have delayed egress doors.


CONTINUED ON LIC809-C...

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
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 4


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
VISIT DATE: 09/13/2024
NARRATIVE
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For the exterior portion, LPA Ramirez observed patio furniture under shading, and the grounds were free of any hazards. LPA observed the emergency disaster and evacuation plan, which is posted at the main entrance behind the front desk.

LPA Ramirez observed that First Aid Kit had all the required components. Medications were locked and inaccessible to residents in care. Toxins were also observed to be locked and inaccessible to residents.

During the tour LPA did not observed the Elderly (RCFE) Complaint Poster (PUB 475), a Deficiency was issued today.

LPA reviewed ten resident files and five staff files. LPA observed that five of five staff records reviewed did not include a Health Screening Report, a Deficiency was issues today.

For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.



LPA Ramirez advised BOM Belanger to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA Ramirez conducted an exit interview with BOM Belanger and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/13/2024 01:16 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: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed that five of five staff records reviewed did not have a Health Screening Report.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee to completed a Health Screening Report (LIC503) for five staff and email proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/13/2024 01:16 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: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA did not observe a complaint poster in areas accesible to residents.
POC Due Date: 09/20/2024
Plan of Correction
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Licensee to post Complaint Poster and email proof to LPA by POC due date.

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: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4