306002954-10-4-2022-22-AS-CDPO-CJVTD7-20221004143751

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002954
Report Date: 10/04/2022
Date Signed: 10/04/2022 02:37:57 PM

Document Has Been Signed on 10/04/2022 02:37 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 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: 94	DATE:	10/04/2022
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	01:44 PM
MET WITH:	West Division Operations Specialist/Acting Executive Director (ED) Lilit Mnatsakanyan		TIME COMPLETED:	02:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to conduct a case management and health and safety check in this facility. LPA De Perio met with West Division Operations Specialist/Acting Executive Director (ED) Lilit Mnatsakanyan and stated the purpose of this visit. LPA De Perio toured the interior and exterior portions of the facility with ED Mnatsakanyan. The facility is a three level structure and is licensed for 155 non-ambulatory residents, of which 15 may be on hospice and 0 may be bedridden. Currently, there are a total census of 94 residents in care. LPA De Perio observed resident bedrooms to be in good repair, and is equipped with clean linens, adequate storage space, and kept free of tripping hazards. Water temperature in restrooms were measured to be at 111.4 degrees Fahrenheit. Smoke and carbon monoxide detectors were operational and most recent fire inspection took place on 11/12/2021, of which inspection was passed. Auditory alarms and wander guard functions were also tested and observed to be operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. LPA De Perio also tested pull cords in resident bathrooms and observed to be operational. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Facility had back-up emergency food and water supply. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and located in multiple areas of the facility. LPA De Perio observed exit stairwells and each floor had an evacuation chair. Facility does not have delayed egress doors.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/04/2022

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For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the main entrance behind the front desk.

LPA De Perio reminded ED Mnatsakanyan to ensure that Guardian roster is up to date and reflects current employees.

For this visit, LPA De Perio did not observe immediate threats on the health and safety of residents in care. No citation has been issued at this time.

An exit interview was conducted and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022

LIC809 (FAS) - (06/04)

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