306002955-10-20-2021-22-AS-MSTC-CJS59Q-20220930194554

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002955
Report Date: 10/20/2021
Date Signed: 10/20/2021 11:55:20 AM

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
10/13/2021 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20211013093456

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: 76	DATE:	10/20/2021
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Business Office Manager Shaima Faisal and Wellness Director Michelle Angcaco.		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not provide adequate supervision of a resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst Michelle Reed arrived at the facility to discuss the complaint allegation. Upon arrival LPA met with Business Office Manager Shaima Faisal and Health and Wellness Director Michelle Angcaco. Records were reviewed and interviews were conducted.
Resident #1(R1) was admitted into the facility on 6/18/21. R1 is nonambulatory and according to staff is independent. R1 uses a scooter and can leave the facility unassisted. Staff assist with bathing and the storage and supply of oxygen. Staff will check on all residents at least once a night. On 10/9/21 at approximately 12am, R1 was found by staff lying on the floor of his room complaining of back pain. R1 had taken off his life alert and could not reach the phone. Staff immediately called 911. R1 was treated for a fracture and is currently at skilled nursing. Wellness Director Michelle Angcaco stated that R1's care needs will be reassessed before he returns to the facility.
Based upon interviews and a review of records, the allegation above is unsubstantiated, meaning that there is not a preponderance of the evidence to prove that staff failed to provide adequate supervision to R1. An exit interview was conducted and a copy of this report was provided to Michelle Angcaco.

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: 10/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

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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