306002955-8-19-2022-22-AS-ETAA-CHFQPF-20220819122039

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002955
Report Date: 08/19/2022
Date Signed: 08/19/2022 12:21:01 PM

Document Has Been Signed on 08/19/2022 12:21 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 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: 66	DATE:	08/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Lana Hammers		TIME COMPLETED:	12:35 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) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with Executive Director Lana Hammers and stated the purpose of this visit. The facility is a five-level structure licensed for one hundred and sixty-four non-ambulatory residents with a hospice waiver for ten. This facility offers Residential Care for the Elderly. At about 10:05 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed residents in care and staff members on duty. LPA toured the interior and exterior portions of the facility. The first floor is for common areas which includes kitchen, dining area, theater room, activities room, hair salon and some storage rooms. Kitchen was in good repair and in a separate room inaccessible to residents. LPA toured the kitchen and saw they had a walk-in refrigerator and freezer. Residents were eating in the dining area and LPA saw that it was in good repair. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were observed to be charged and operational. Resident rooms were selected at random for inspection from floors 2 through 5. Resident rooms (216, 252, 346, 349, 435, 447, 523, 545) were inspected for selection. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Resident rooms did have private restrooms. Resident bathrooms were observed to be in good repair and provided with grab bars and hot water was measured between 106.0 degrees and 122.7 degrees Fahrenheit. Administrator was made aware of water temperature regulations. LPA also notice handing washing signs throughout the facility. LPA Tapia notice PUB 475 poster posted in a prominent location. Fire alarms and carbon monoxide alarms were currently being tested while LPA was conducting inspection. For the exterior portion, facility had an outside patio with shaded seating and grounds were free of tripping hazards.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

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 NOHL RANCH	FACILITY NUMBER: 306002955
	VISIT DATE: 08/19/2022

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LPA Tapia reviewed the COVID 19 mitigation plan and Emergency Disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed and no citation was issued. One advisory was issued today.

LPA Tapia conducted an exit interview with Executive Director Lana Hammers and copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

LIC809 (FAS) - (06/04)

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