306003639-7-24-2026-22-AS-AORZ-DWFQ8W-20260729115727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003639
Report Date: 07/24/2026
Date Signed: 07/24/2026 03:29:35 PM

Unsubstantiated

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
03/11/2026 and conducted by Evaluator RoseMarie Ruppert

COMPLAINT CONTROL NUMBER: 22-AS-20260311144516

FACILITY NAME:	BROOKDALE BREA		FACILITY NUMBER:	306003639
ADMINISTRATOR:	DANNY VERA		FACILITY TYPE:	740
ADDRESS:	285 W CENTRAL AVE		TELEPHONE:	(714) 671-7898
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY:	110	CENSUS: 70	DATE:	07/24/2026
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Laurie Galal, Executive Director (ED)		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident developed Stage 4 pressure injury due to lack of care/supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by the receptionist at 2:55pm. LPA was introduced to the new Executive Director (ED) Laurie Galal, and explained the purpose of the visit.

During the course of the investigation, the Department interviewed staff and witnesses; and subpoenaed and reviewed Hospice and Hospital medical records. The investigation revealed the following:

Per Resident #1’s (R1)'s Medical Assessment, dated November 10, 2025, R1 has a diagnosis of necrosis of right femur. Prior to moving into Brookdale Brea on January 30, 2026, R1 resided at a skilled nursing facility. R1 resided at Brookdale Brea from January 30, 2026 – March 8, 2026.

(Continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260311144516

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 BREA	FACILITY NUMBER: 306003639
	VISIT DATE: 07/24/2026

NARRATIVE

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(Continued from LIC 9099)

Resident #1 (R1) was sent to the hospital on February 5, 2026, and returned on February 9, 2026, with a suprapubic catheter; which was maintained by home health. R1 was admitted to hospice services and per hospice documentation, received services for pain management and comfort care. An updated medical assessment from February 9, 2026, documented R1 has a history of skin condition or breakdown.

Beginning on February 16, 2026, R1 received hospice services once a week for wound care. Per interview with facility staff, the facility requested additional wound care for a pressure injury on the sacrum; since the wound care provided to R1 was not sufficient. On February 24, 2026, R1 had an additional assessment by Wound Pros. R1 was sent out to the hospital on March 2, 2026, due to the pressure injury not healing.

R1 returned to the facility on March 5, 2026, and the facility continued to follow the Primary Care Provider’s (PCP) orders until March 8, 2026. On March 8, 2026, the Health and Wellness Director (HWD) sent R1 to the hospital since the pressure injury showed no improvement. HWD stated they did not receive hospice documentation regarding the pressure injury being stage 3 until the HWD made the decision to send the resident out on March 8, 2026. Hospice Provider Notes to the facility, dated February 26, 2026, stated the pressure injury was stage 3.

The resident did not return to the facility and resided at Kaiser Permanente until March 23, 2026. While hospitalized, it was reported the pressure injury measured 12 cm in length on the sacrum and unstageable right heel injury measured 3 cm.

LPA interviewed three of three staff members. Three of three staff denied the allegation and stated the facility continuously monitored the resident and communicated with the hospice agency to request additional wound care. Two of three staff who provided direct care to the resident stated they continued to speak with the hospice agency and felt they were unresponsive. The facility decided to send the resident out on March 8, 2026 due to insufficient wound care being provided.

LPA attempted to interview the hospice agency three different times. LPA interviewed two of three residents. Two of three residents stated they were happy with the quality of care provided and denied the allegation of neglect and lack of supervision. LPA interviewed one witness who denied the allegation that Resident developed Stage 4 pressure injury due to lack of care/supervision. The witness stated that the hospice agency was to provide wound care and that the facility was communicative and followed orders.

(Continued on LIC 9099-C1)

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260311144516

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 BREA	FACILITY NUMBER: 306003639
	VISIT DATE: 07/24/2026

NARRATIVE

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(Continued from LIC 9099-C)

Based on LPA’s interviews, observations and document review, the allegation that Resident developed Stage 4 pressure injury due to lack of care/supervision is Unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with ED Laurie Galal and a copy of this report and LIC 811 was provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

LIC9099 (FAS) - (06/04)

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