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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002954
Report Date: 08/09/2023
Date Signed: 08/09/2023 12:14:52 PM

Document Has Been Signed on 08/09/2023 12:14 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: 63DATE:
08/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Executive Director (ED) Shannon HowellTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Celine De Perio conducted a case management visit to the facility in conjunction with complaint: 22-AS-20221220140629. LPA De Perio explained reason for visit and was greeted by Executive Director (ED) Shannon Howell.

During the course of the investigation, it was requested on 01/04/2023 with Operational Specialist/Acting Executive Director at the time, to provide the following documents to Community Care Licensing (CCL).

The following documents were requested on 01/04/2023, however were not provided:
  • Facility internal investigation
  • Pendant reports
  • Resident care notes
  • Resident signed waiver

For today's visit, citations were issued.

An exit interview was conducted with ED Howell.

A copy of this report and Appeal Rights were provided and explained.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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 2
Document Has Been Signed on 08/09/2023 12:14 PM - It Cannot Be Edited


Created By: Celine DePerio On 08/09/2023 at 11:45 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BROOKDALE IRVINE
FACILITY NUMBER: 306002954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2023
Section Cited

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87755 Inspection Authority of the Licensing Agency
(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours...
This requirement is not met as evidence by:
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Based on record reviews and interviews, licensee did not comply with the regulation cited and did not provide CCL staff with the requested documents.
This poses a potential health and safety risk to residents in care.
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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:Luz Adams
LICENSING EVALUATOR NAME:Celine DePerio
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023


LIC809 (FAS) - (06/04)
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