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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306002962
Report Date:
06/12/2020
Date Signed:
06/12/2020 04:46:20 PM
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 BROOKHURST
FACILITY NUMBER:
306002962
ADMINISTRATOR:
KIMIA ATAEIAN
FACILITY TYPE:
740
ADDRESS:
15302 BROOKHURST ST
TELEPHONE:
(714) 775-6775
CITY:
WESTMINSTER
STATE:
CA
ZIP CODE:
92683
CAPACITY:
164
CENSUS:
DATE:
06/12/2020
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
03:45 PM
MET WITH:
Kimia Ataeian
TIME COMPLETED:
04:36 PM
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Licensing Program Analyst (LPA) Jim August contacted the facility via telephone to conduct a case management visit via telephone due to COVID-19 and precautionary measures. LPA identified himself and discussed the purpose of the call.
The case management is in regard to an incident report received by Community Care Licensing (CCL) on 6/9/2020. LPA discussed the incident with Executive Director (ED) Kimia Ataeian and obtained all pertinent details about the incident. ED Ataeian immediately cross reported the incident and contacted R1’s POA as well as the Westminster Police Department.
No deficiencies are being cited. An exit interview was conducted with ED Ataeian over the phone and a copy of this report will be provided via email ED Ataeian to sign the report and return via email within 24 business hours.
SUPERVISOR'S NAME:
Marina Stanic
TELEPHONE:
(714) 703-2851
LICENSING EVALUATOR NAME:
James August
TELEPHONE:
(951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE:
06/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/12/2020
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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