306002954-11-8-2024-22-AS-AORZ-DCGUJN-20241231143748

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002954
Report Date: 11/08/2024
Date Signed: 11/08/2024 04:03:33 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
06/19/2024 and conducted by Evaluator Dwayne L Mason

COMPLAINT CONTROL NUMBER: 22-AS-20240619132458

FACILITY NAME:	BROOKDALE IRVINE		FACILITY NUMBER:	306002954
ADMINISTRATOR:	CARRIE GALLOWAY		FACILITY TYPE:	740
ADDRESS:	10 MARQUETTE		TELEPHONE:	(949) 854-3766
CITY:	IRVINE	STATE: CA	ZIP CODE:	92612
CAPACITY:	155	CENSUS: 131	DATE:	11/08/2024
		UNANNOUNCED	TIME BEGAN:	01:54 PM
MET WITH:	Iris Nunez - Resident Care Coordinator		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Facility lacks staff

INVESTIGATION FINDINGS:

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This unannounced investigation inspection by Licensing Program Analysts (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPAs arrived at the facility and were greeted by facility staff. LPA met with Iris Nunez, Resident Care Coordinator, and explained the nature of the inspection.

The department received a complaint on 6/19/2024 stating the facility lacks staff. During the investigation, the Department interviewed Executive Director, staff and residents in care.

(continued on LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

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 3

Control Number 22-AS-20240619132458

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BROOKDALE IRVINE	FACILITY NUMBER: 306002954
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/15/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.	1 2 3 4 5 6 7	Based on the staff roster reviewed on 11/8/2024, LPA determined that, since June 2024, the facility has hired: 2 Cooks, 8 Servers and 2 Dishwashers. LPA determined facility fulfilled the POC. POC cleared during visit
	8 9 10 11 12 13 14	The Licensee did not comply with the section cited above due to 4 out of 4 staff stating the facility is understaffed. This poses a potential health, safety or personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20240619132458

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BROOKDALE IRVINE	FACILITY NUMBER: 306002954
	VISIT DATE: 11/08/2024

NARRATIVE

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(continued from LIC9099)

On 6/24/2024 LPA Mason conducted a visit to the facility. LPA obtained copies of the staff roster, resident roster and staff schedule. LPA conducted interviews with ED, 4 staff and 9 residents. ED did not explicitly state whether or not the facility is understaffed. Of the staff interviewed, 4 out of 4 stated the facility is understaffed. Of the residents interviewed, 1 out of 9 stated the facility is understaffed. During the interview, ED stated the facility is hiring. Of the staff interviewed, 3 out of 4 stated the facility was hiring at the time of the visit.

Based on staff interviews conducted, LPA determined that the facility is understaffed. The preponderance of evidence standard has been met. The allegation is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024

LIC9099 (FAS) - (06/04)

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