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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002954
Report Date: 06/02/2022
Date Signed: 06/02/2022 11:26:40 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/27/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220527153953
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
UNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Becky Kruse and Carrie GallowayTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
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9
Staff are not allowing residents privately paid personal assistant to assist resident
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Kimberly Lyman conducted a 10 day complaint visit to initiate an investigation into the above allegation. 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.
During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegation that staff are not allowing resident's privately paid personal assistant to assist resident, the investigation revealed the following: Resident 1(R1) has a 24 hour care companion. Facility has notified responsible party that care companions are for companionship only and not for any caregiving duties. Facility staff are required to perform caregiving duties as part of basic services offered by the facility and department guidelines. Per Community Care Licensing regulation 87411, all facility staff performing assistance with activities of daily living shall receive initial and annual training. Care companions are not facility staff and not held to those requirements thus unable to provide assistance. CONTINUED ON LIC 9099C DATED 06/02/2022.
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20220527153953
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BROOKDALE IRVINE
FACILITY NUMBER: 306002954
VISIT DATE: 06/02/2022
NARRATIVE
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Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. 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
LIC9099 (FAS) - (06/04)
Page: 2 of 2