306002955-2-9-2024-22-AS-LMOA-D2W43X-20240228174529

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002955
Report Date: 02/09/2024
Date Signed: 02/09/2024 12:12:17 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
01/26/2024 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240126094209

FACILITY NAME:	BROOKDALE NOHL RANCH		FACILITY NUMBER:	306002955
ADMINISTRATOR:	KELLY JACOBS		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:	02/09/2024
		UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Tierny Wilburn- Operations Specialist		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Staff are not cleaning facility properly.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho made a subsequent unannounced visit to deliver the findings into the above allegation. LPA met with Operations Specialist (OS) Tierny Wilburn and stated the purpose of the visit after reviewing the allegation. During the initial complaint inspection conducted on January 31, 2024, between 3:05pm to 5:00pm, the following were observed:
LPA and OS Wilburn toured and inspected all common areas on levels 1-3. There are no common areas on levels 4-5. There is a strong odor lingering in the lobby past the living room and by the north elevator. The odor was still present on today's date as well. Food particles and dust have accumulated below the dining tables, and the floor was sticky. The floor of the north/south elevator were sticky and had a strong smell of urine inside the north elevator. The floor in the four bathrooms located on the first floor were sticky and had a smell of urine. LPA and OS Wilburn observed two full trash bags in front of units 344 and 345 which were immediately removed from the hallway and disposed during inspection. The laundry sink on the 3rd floor required a deep cleaning due to the soap buildup. Pile of leaves were observed surrounding the dog park on the third floor and the patio area on the second floor.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

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-20240126094209

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BROOKDALE NOHL RANCH	FACILITY NUMBER: 306002955
	VISIT DATE: 02/09/2024

NARRATIVE

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Based on the observations, the preponderance of evidence standard has been met, therefore the following allegation: Staff are not cleaning facility properly is deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. A deficiency is being cited on the attached LIC 9099D.

An exit interview was conducted with Operations Specialist Tierny Wilburn, and a copy of this report was provided at the end of the visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20240126094209

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BROOKDALE NOHL RANCH	FACILITY NUMBER: 306002955
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/09/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/16/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	OS Wilburn stated that the facility will provide photos of areas that have been cleaned, to provide a cleaning schedule of all common areas, to provide proof of training to housekeeping staff, and to submit an Acknowlegement of Understanding of the said regulation to LPA via email by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on observation with OS Wilburn, facility was not clean, safe, and sanitary on levels 1-3 which poses a potential, Health, Safety, and Personal Rights risk to persons in care.	8 9 10 11 12 13 14
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

LIC9099 (FAS) - (06/04)

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