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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002962
Report Date: 08/12/2024
Date Signed: 08/13/2024 10:26:06 AM


Document Has Been Signed on 08/13/2024 10:26 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/13/2024 09:10 AM

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

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Licensing Program Analyst (LPA) Michael Tea conducted a case management incident visit to follow up on an incident report received by Community Care Licensing (CCL) on August 9, 2024, submitted by Health and Wellness Director (HWD) Suzette Paige, LVN. LPA was greeted and allowed entrance into the facility by Executive Director (ED) John Goodwin. LPA explained the reason for the visit.

During the inspection, LPA and ED toured the facility and inspected R1’s room. LPA conducted health and safety checks on residents present and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA checked perishable and non-perishable food supply and it was adequately stocked at time of visit. The electricity and water were running, the facility had soap and paper towels, and the medications, sharps, and toxins were properly stored. LPA interviewed ED Goodwin and requested and reviewed copies of R1’s resident file and S1’s staff file.



On August 7, 2024, facility management concluded their investigation, S1 emailed their resignation before receiving investigation results. Facility management concluded they were going to terminate S1 employment. In Guardian, S1 has been shown to be separated on August 7, 2024.

There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited at this time.

An exit interview was conducted with Executive Director, John Goodwin and a copy of this report was provided at exit.

**THIS IS AN AMENDED REPORT**
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
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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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: 08/12/2024
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This page was created in error.

**THIS IS AN AMENDED REPORT**

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC809 (FAS) - (06/04)
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