306002954-12-13-2024-22-AS-AORZ-DCFV3A-20241230150423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002954
Report Date: 09/13/2024
Date Signed: 12/13/2024 09:35:39 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
05/15/2024 and conducted by Evaluator Michael Tea

COMPLAINT CONTROL NUMBER: 22-AS-20240515084741

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:	DATE:	09/13/2024
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Sharin Belanger		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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- Facility staff charged for services not rendered

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Tea made an unannounced complaint visit on this day to deliver findings for the allegation mentioned above. LPA met with Executive Director (ED) Shannon Howell.

It was alleged that facility staff charged for services not rendered. During the investigation LPA interviewed residents and staff; checked resident files; and reviewed resident invoices; personal service plans; assessments; staff progress notes; and daily shift reports. The investigation determined the following:

The facility was supposed to provide medication; dressing and grooming; and showering or bathing services which were discussed in the personal service plan and assessment summary and admission agreement of Resident 1 (R1).

(Continued on LIC9099C)

**THIS IS AN AMENDED REPORT**

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
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.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240515084741

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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Per interview with R1, R1 reported they receive assistance with the following activities of daily living: medication and daily shower services. R1 states the facility has been good with keeping up with their services and that they feel the facility is run very well aside from a water pipe leakage incident in their room. R1 said that the staff are very good and have never bullied or pressured them into anything. R1 confirmed that Resident 2 (R2) speaks for them and helps a lot. R1 has no complaints about R2’s help and asserted that R2 is not controlling and has no complaints about R2.

Interviews with facility staff reported that R2 interferes with R1’s activities of daily living (ADL) services. The Facility Executive Director Shannon Howell and management team addressed the problem with the responsible party of R1 and R2 however staff reported the interference continued as R1 and R2 are always together. Interviews with four of four staff confirm that R2 interferes with personal services provided to R1. One staff confirmed that despite R2’s interference, they try to go through and provide the services and do their job. The staff reported letting R2 know they are providing the services to R1.

Per interview with R2, R2 stated staff asks them for help when R1 needs to take a shower. Then they just leave R1 in a towel all wet and does not help dress R1. Per R2 this is a service that is to be provided to R1. R2 said that they help R1 because R1 asks for their help. R2 said that they are fighting for R1 and they don’t like to see R1 being treated badly and is happy to help.

Progress Notes and Shift reports notates R1 would at times refuse to take a showers; switch shower times for later in the afternoon; or have R2 assist them with their shower before staff could assist R1.

Therefore based on LPA Tea's observation and interviews conducted and records review the allegations the staff charged for services not rendered has been determined to be unsubstantiated meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies cited at this time and an exit interview was conducted with Executive Director Shannon Howell and a copy of the report and confidential names list was provided to the facility.

**THIS IS AN AMENDED REPORT**

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
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

LIC9099 (FAS) - (06/04)

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