306002962-7-19-2024-22-AS-MTEA-D7C23N-20240719170238

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002962
Report Date: 07/19/2024
Date Signed: 07/19/2024 05:02:57 PM

Document Has Been Signed on 07/19/2024 05:02 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BROOKDALE BROOKHURST		FACILITY NUMBER:	306002962
ADMINISTRATOR:	JOHN GOODWIN		FACILITY TYPE:	740
ADDRESS:	15302 BROOKHURST ST		TELEPHONE:	(714) 775-6775
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY:	164	CENSUS:	DATE:	07/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:			TIME COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:15 AM, LPA Tea was greeted and granted entry into the facility by Business Operations Manager, Danielle Chairez and explained the reason for the visit. Facility is licensed for 148 non-ambulatory residents, of which 22 may be bed-ridden, but limited to the first and second floor, and a hospice waiver for 22 residents. Currently there are 110 residents during today's visit. The Executive Director (ED), John Goodwin arrived shortly after to assist during the visit.

LPA Tea along with ED Goodwin toured the facility at 9:27 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a three-story building, with a memory care wing, called “Clare Bridge” on the first floor. In the middle of the building is a courtyard with shaded patio seating and a fenced in water fountain with koi fishes swimming. Memory Care unit has a garden sitting area of it's own in the back that is secured. LPA tested delayed egress around the memory care garden to be operational. Staff came immediately within minutes when the alert for delayed egress went off. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. The fire alarm system of the facility is monitored and maintained by a third-party company. Fire extinguishers are fully charged throughout the facility. LPA observed evac chairs in every stairwell in the facility for emergencies. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. In the memory care unit in the dining room area and one resident room, LPA observed cleaning supplies and disinfectants accessible to residents in care, after the observation was made ED had staff secured the toxins away from residents. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 110.6 F degrees and 117.5 F degrees. LPA pulled emergency pendants in resident’s bathrooms; staff came in the room in a matter of one to two minutes in response. Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen and dining room was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed emergency food and water supplies stored in storage areas in the facilities.

Annual inspection continuation on LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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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Document Has Been Signed on 07/19/2024 05:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87750(f)(2)

Care of Persons with Dementia: The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation during facility tour of Memory Care Unit, there were cleaning supplies and disinfectants found accessible in memory care unit dining room area and one resident's room. This poses an immediate healthy and safety risk to residents in care.
	POC Due Date: 07/22/2024
	Plan of Correction
1 2 3 4	During the annual inspection facility tour, director had staff removed and secured cleaning supplies and disinfectants inaccessible from the memory care unit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/19/2024

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LPA Tea observed residents doing exercises and partaking in activities in the activity room. The facility provides different activities for residents daily, which are posted throughout the facility.

LPA Tea reviewed ten resident files and ten staff files. resident files and staff files contained all required documentation.

At 2:54 PM LPA reviewed medication storage and administration. Medications are stored in locked carts in each floor of the facility. Medications are being administered per physician order.

LPA interviewed clients regarding their quality of care and spoke to staff present regarding care provided.

The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with ED John Goodwin and a copy of this report was given to the facility along with a copy of the LIC 858, 858C; 859, 859C; 809-D and Appeal Rights.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

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