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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002954
Report Date: 06/02/2022
Date Signed: 06/02/2022 11:28:22 AM


Document Has Been Signed on 06/02/2022 11:28 AM - 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: 105DATE:
06/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Becky Kruse and Carrie GallowayTIME COMPLETED:
11:47 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted a case management visit to follow up on an incident report submitted to Community Care Licensing on 05/25/2022. LPA was greeted and granted entry into the facility by Health and Wellness Director Becky Kruse and explained the reason for the visit. Carrie Galloway joined the visit in progress.

Incident report dated 05/21/2022 indicated that Irvine PD had arrived at the facility to check on Resident 1 (R1). R1 had called the Veterans Administration (VA) Hospital who in turn called the authorities after the representative determined the resident may harm the resident. Irvine PD assessed the resident and determined the resident did not pose a risk of harm. Irvine PD left a report number, 22-05-8930, but declined to open a case. VA representative indicated resident had stated the resident would take all the resident's medications to harm the resident. Facility removed the resident's medications and put resident on two hour checks. R1 is currently on med management.

During the visit, LPA met with R1. R1 indicated the situation was a misunderstanding and the resident had no intention of harm, just frustration with maneuvering the VA system. R1 stated no desire to harm oneself. Resident has had no incidents of suicidal ideation or self harming behavior. Physician report dated 04/15/2022 indicates R1 is mostly independent and at time of report was able to mange own medications. There is no diagnosis of Dementia or Mild Cognitive Impairment.


No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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