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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002954
Report Date: 12/13/2024
Date Signed: 12/13/2024 09:33:51 AM

Substantiated


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 IRVINEFACILITY NUMBER:
306002954
ADMINISTRATOR:CARRIE GALLOWAYFACILITY TYPE:
740
ADDRESS:10 MARQUETTETELEPHONE:
(949) 854-3766
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY:155CENSUS: 85DATE:
12/13/2024
UNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Shannon Howell TIME COMPLETED:
09:15 AM
ALLEGATION(S):
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- Facility staff did not follow admission agreement
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 did not follow admission agreement. 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:

On the signed Admission Agreement on page 2 Section I Clause B “Personal Service Plan,” states “Prior to moving in and periodically throughout your residency, we will use a personal service assessment to determine the personal services you require. The personal service assessment will be used to develop your Personal Service Plan. The results of the assessment, our method for evaluating your personal care needs, and the cost of providing the additional services (the “Personal Service Rate”) will be shared with you.” Responsible Party said they were not given notice about the updated services for R1.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
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-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: 12/13/2024
NARRATIVE
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Interview with Executive Director (ED) reported that R1’s responsible party were aware of the services being provided and billed every month. However, personal service plan and assessment notices on April 14, 2023, did not have signatures from R1’s responsible party. R1’s responsible party signed a new personal service plan dated October 20, 2023, thus agreeing to services to be provided. Since services plan dated April 14, 2023, was not signed, there is no proof or acknowledgement that R1’s responsible party agreed to updated services being provided from the time period of April 14, 2023, through October 20, 2023.

Therefore, based on the preponderance of evidence through records reviewed and interviews the allegation facility staff did not follow admission agreement is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.



The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted with Executive Director Shannon Howell and a copy of this report and appeal rights was provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2024
Section Cited
HSC
1569.657(a)
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Rate increase due to change in level of resident care; notice ... (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. This requirement is not met as evidenced by:
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Management staff will provided written statement of understanding for regulation that was cited and emailed to LPA. And will conduct an inservice training on admission agreements and provide proof to LPA by POC due date.
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Responsible party of R1 stated they did not receive notice or signed or agreed with Personal Service Plan updates. No sign copy of Personal Service Plan for disputed charges on April 14, 2023 service plan updates.
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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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3