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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002962
Report Date: 10/31/2025
Date Signed: 10/31/2025 10:17:02 AM

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
06/09/2025 and conducted by Evaluator Michael Tea
COMPLAINT CONTROL NUMBER: 22-AS-20250609112449
FACILITY NAME:BROOKDALE BROOKHURSTFACILITY NUMBER:
306002962
ADMINISTRATOR:JOHN GOODWINFACILITY TYPE:
740
ADDRESS:15302 BROOKHURST STTELEPHONE:
(714) 775-6775
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:164CENSUS: 114DATE:
10/31/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:John Goodwin, Suzette PaigeTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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- Resident sustained multiple pressure injuries due to neglect
INVESTIGATION FINDINGS:
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This is the final report of the investigation completed by the Department. LPA met with Executive Director (ED) John Goodwin and Health & Wellness Director (HWD) Suzette Paige. On June 11, 2025, the Orange County Adult and Senior Care Regional Office received a complaint alleging that a resident sustained multiple pressure injuries due to neglect. The investigation determined as follows:

Resident 1 (R1) was admitted to the facility on February 16, 2018. Per physician report dated November 06, 2024, R1 has some motor impairment/paralysis and is considered non-ambulatory with no history of skin breakdowns. The facility completed an assessment of R1 on March 08, 2023, in which it was noted R1 had fallen within the last 12 months. Universal fall precautions were put in place including orienting resident to environment & familiarizing them with the facility call system.

(Complaint Investigation Report continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 22-AS-20250609112449
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 BROOKHURST
FACILITY NUMBER: 306002962
VISIT DATE: 10/31/2025
NARRATIVE
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On June 08, 2025, R1 was found by MedTech 1 (MT1) lying on their bedroom floor at approximately 9:30 AM after staff reported not seeing R1 at breakfast. Per facility policy, staff are to check on residents when they do not show up for meals. Emergency services were contacted and R1 was transported to UCI Medical Center where he was treated for pressure injuries, abrasions and signs of prolonged immobility. Per records obtained, EMS report confirms a call at 9:23 AM, with arrival at 9:30 AM. The EMS report noted pressure ulcer to left check, abrasions to chest and knee and stable vital signs. Per UCI Medical Records R1 was admitted on June 8, 2025, for trauma and sepsis secondary to gangrenous cholecystitis. The medical notes document that R1 was found down after approximately 24 hours in which large pressure ulcer was found on the left cheek; an abrasion to chest and right knee; strong smell of urine; clothes soiled; and soft tissue trauma consistent with prolonged immobility. UCI medical documents and EMS report corroborate that injuries resulted from prolonged immobility.

Per interview with Health & Wellness Director (HWD) Suzette Paige, R1 was independent and typically attended all meals. She received a call from MT1 that R1 was found on the floor because they had missed breakfast. HWD Paige stated that the night shift failed to perform required checks despite policy requiring one per shift. From records obtain, Brookdale Senior Living has a Night Check Policy – CS-100-16 Effective April 1997 where resident care staff should make night checks of the residents. Interviews with MedTech and Caregiver confirmed that there was no overnight welfare checks completed on June 7th & 8th. Facility did not follow or practice the policy of verifying the independent residents’ well-being during night shifts which contributed to the prolonged delay in discovery of R1 in their apartment. Per interviews, two staff interviewed mentioned there was a facility informal rule, to wait for two consecutive missed meals before checking on residents. This informal rule practiced by facility staff demonstrates neglect with delayed responses and violation of the facility procedures. The facility failed to provide adequate supervision and neglected to ensure the health and safety of residents in care.

Based on interviews conducted and records reviewed, Resident sustained multiple pressure injuries due to neglect. The following is cited by the California Code of Regulations, Title 22, Division 6.

A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f)

(Complaint Investigation Report continued on LIC9099-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20250609112449
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 BROOKHURST
FACILITY NUMBER: 306002962
VISIT DATE: 10/31/2025
NARRATIVE
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An exit interview was conducted and a copy of this report, LIC809-D, appeal rights and confidential names list was provided to Executive Director and Health & Wellness Director.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20250609112449
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 BROOKHURST
FACILITY NUMBER: 306002962
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2025
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidence by:
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Facility agrees to sign a statement of understanding for the regulation. Facility also agrees to conduct an in-service on wellness checks and Facility's Night Check Policy and forward proof to LPA by POC due date.
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Based on interviews with staff and witnesses, as well as records reviewed, it was determined that Resident 1 (R1) sustained pressure injuries resulting from a lapse in supervision. Evidence indicates that R1 was found on the floor and remained there for an extended period of time. This poses an immediate health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4