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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002962
Report Date: 08/13/2024
Date Signed: 08/13/2024 10:28:23 AM


Document Has Been Signed on 08/13/2024 10:28 AM - 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 BROOKHURSTFACILITY NUMBER:
306002962
ADMINISTRATOR:JOHN GOODWINFACILITY TYPE:
740
ADDRESS:15302 BROOKHURST STTELEPHONE:
(714) 775-6775
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:164CENSUS: 113DATE:
08/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:John GoodwinTIME COMPLETED:
10:43 AM
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today's visit was to conduct a case management. LPA Tea was greeted and granted entry into the facility by Executive Director John Goodwin.

On this day LPA Tea amended LIC809, LIC809C dated 08/12/2024. LPA reviewed amended report with Executive Director.

An exit interview was conducted with the executive director . A copy of this report and amended LIC809, LIC809C was provided to the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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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