306002955-8-20-2021-22-AS-SSAS-CFTTKJ-20220628144757

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002955
Report Date: 08/20/2021
Date Signed: 08/20/2021 02:38:58 PM

Unsubstantiated

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
07/12/2021 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210712121318

FACILITY NAME:	BROOKDALE NOHL RANCH		FACILITY NUMBER:	306002955
ADMINISTRATOR:	HAMMERS, LANA		FACILITY TYPE:	740
ADDRESS:	380 S ANAHEIM HILLS RD		TELEPHONE:	(714) 974-1616
CITY:	ANAHEIM HILLS	STATE: CA	ZIP CODE:	92807
CAPACITY:	266	CENSUS: 69	DATE:	08/20/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Administrator Lana Hammers		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility did not refund preadmission fee(s) to resident(s).
Facility staff forged authorized representative's signature on Admission agreement(s)

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Michelle Reed made an unannounced visit to the facility for the purpose of presenting the findings of the complaint investigation. Upon arrival, LPA met with Administrator Lana Hammers. The investigation consisted of interviews with Administrator and witnesses as well as documentation. The following was determined:

On 6/19/21, a Preadmission Appraisal was completed for R1 and R2. An Admission Agreement was signed on 6/24/21 with a move in date of 8/1/21. On 7/1/21 a 30 day notice was given by R1 and R2 that they would not be moving into the facility. Regulation states that a refund of at least 80 percent of the preadmission fee in excess of $500 shall be provided if the applicant does not enter the facility after a preadmission appraisal is conducted, or the resident leaves the facility for any reason during the first month of residency. On 8/19/21 Brookdale posted a refund of $839.35 that will be mailed within 2 days to R1 and R2. The admission agreement was also reviewed regarding the forged signature allegation. The document was signed using the computer system DocuSign by all parties. DocuSign is a valid signature.

CONTINUED-

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20210712121318

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 NOHL RANCH	FACILITY NUMBER: 306002955
	VISIT DATE: 08/20/2021

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 26 27 28 29 30 31 32	Based upon interviews and a review of records, the allegations above are unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged allegations occurred. An exit interview was conducted and a copy of this report was provided to Administrator Lana Hammers.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC9099 (FAS) - (06/04)

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