<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002962
Report Date: 06/16/2022
Date Signed: 06/16/2022 02:03:07 PM


Document Has Been Signed on 06/16/2022 02:03 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 BROOKHURSTFACILITY NUMBER:
306002962
ADMINISTRATOR:KIMIA ATAEIANFACILITY TYPE:
740
ADDRESS:15302 BROOKHURST STTELEPHONE:
(714) 775-6775
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:164CENSUS: 91DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Kimia AtaeianTIME COMPLETED:
02:15 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) Jessica Cho conducted an unannounced required annual inspection focusing primarily on the Infection Control. At 11:47 am, LPA was greeted and granted entry by Executive Director/Administrator (Admin) Kimia Ataeian after completing the Coronavirus 2019 (COVID-19) screening procedure. As of today, there are no active COVID-19 cases. Facility screens and documents temperature for all staff and visitors on a sign in sheet. Upon entry, LPA observed the required COVID-19 precautionary signs posted on the two entrance doors. Tthe PUB475 See Something, Say Something poster was not observed by the main entryway. The Administrator's Certificate for Kimia Ataeian expires on 9/6/2022.

Around 12:00 pm, LPA toured the interior and exterior portions of the facility with Admin Ataeian. The facility is a three level structure and licensed for one hundred fourty-eight non-ambulatory residents; of which twenty two may be bedridden, which are limited to the first and second floor only; and has a hospice waiver for twenty-two. Currently, there are a total of ninety one residents of which seventeen are in Memory Care (MC) and seventy four are in Assisted Living (AL). Facility appeared clean and sanitary in all areas observed. LPA randomly inspected a total of twelve rooms; two rooms each in AL and MC located on the first floor; and four rooms each on the second and third floor. All twelve rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxides tested operational. The restrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water measured between the ranges of 111.3 to 117.8 degrees Fahrenheit in all twelve restrooms. LPA observed hand washing signs, paper towels, and hand soaps in the community restrooms. Facility had hand sanitizers mounted on the wall throughout the facility and in the common areas. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to the residents in care and were stored in the Medication Room. Fire extinguishers were mounted and charged. For the exterior portion, LPA observed patio furniture in the courtyard under ample shading, and the grounds were free of tripping hazards.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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 BROOKHURST
FACILITY NUMBER: 306002962
VISIT DATE: 06/16/2022
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
26
27
28
29
30
31
32
LPA observed the emergency disaster and evacuation plans. Facility had back-up emergency food and water supply. The First Aid Kits had all the required components, and the facility had sufficient PPEs as well as testing kits stored in the Storage Rooms. Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed.

LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior 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. Residents have access to two tablets provided by the facility upon request.

LPA reviewed the approved COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit, and the licensee will follow-up with the corrections. An exit interview was conducted with Administrator Kimia Ataeian, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3