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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002955
Report Date: 09/21/2023
Date Signed: 09/21/2023 02:29:30 PM


Document Has Been Signed on 09/21/2023 02:29 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 RANCHFACILITY NUMBER:
306002955
ADMINISTRATOR:KELLY JACOBSFACILITY TYPE:
740
ADDRESS:380 S ANAHEIM HILLS RDTELEPHONE:
(714) 974-1616
CITY:ANAHEIM HILLSSTATE: CAZIP CODE:
92807
CAPACITY:266CENSUS: 72DATE:
09/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Kelly JacobsTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit to follow-up on a death report received by Community Care Licensing on 8/31/2023. LPA met with Executive Director (ED) Kelly Jacobs and explained the reason for the visit.

Death report dated 8/30/2023 indicated that on 8/29/2023 at about 12:01 am, Staff found Resident 1 (R1) with “no pulse and no breath sounds.” Cause of death was noted as unknown.

LPA followed-up with facility regarding death report by phone and spoke with Wellness Director (WD) Michelle Woods, who stated R1 had been diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and Primary Care Physician (PCP) had suggested R1 be put on hospice but R1’s family had declined.

During today’s visit, R1’s PCP was present at the facility and an interview was conducted regarding R1’s cause of death. PCP confirmed R1 was diagnosed with COPD and paralyzed diaphragm. PCP also confirmed they had suggested hospice to R1’s family on more than one occasion, with the last instance occurring days prior to R1’s death. Per PCP, it is believed R1 suffered a heart attack.

No further action is required.

Based on today’s observations, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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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