306002955-12-10-2021-22-AS-SSAS-CKR72Q-20221031211707

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002955
Report Date: 12/10/2021
Date Signed: 12/10/2021 02:51:33 PM

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
12/03/2021 and conducted by Evaluator Michelle Reed

COMPLAINT CONTROL NUMBER: 22-AS-20211203090053

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: 70	DATE:	12/10/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Health and Wellness Director Michelle Angcaco and Health and Wellness Coordinator Michelle Woods		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility staff did not ensure that resident was adequately fed

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 Health and Wellness Director Michelle Angcaco and Health and Wellness Coordinator Michelle Woods. Records were reviewed and interviews were conducted with staff and Resident #1 (R1).
(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 and takes his own medications. Staff assist with bathing and the storage and supply of oxygen. R1 eats breakfast and dinner and will occassionly come down to lunch if he misses breakfast. R1 stated that he does eat and that the food is good. If he does not go to the dining room he will call for tray service. The facility provided documentation as well as tray service receipts on today's date showing that R1 had eaten on days prior to his hospitalization on 12/1/21.

Based upon interviews and a review of records the above allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to Michelle Angcaco.

Unfounded

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: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

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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