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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003639
Report Date: 09/08/2023
Date Signed: 09/08/2023 02:18:25 PM


Document Has Been Signed on 09/08/2023 02:18 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:BROOKDALE BREAFACILITY NUMBER:
306003639
ADMINISTRATOR:SARAH DEVOREFACILITY TYPE:
740
ADDRESS:285 W CENTRAL AVETELEPHONE:
(714) 671-7898
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:110CENSUS: 82DATE:
09/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Samantha LoleTIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit for the purpose of following-up on an incident report received by Community Care Licensing on 9/01/2023. LPA met with Staff 3 (S3), Resident Care Coordinator Samantha Lole and explained the reason for the visit.

Incident report indicated that on 8/31/2023 at about 8:00 p.m., Resident 1 (R1) could not be located by facility staff. Police were called and it was determined R1 had been found offsite and transported to a local hospital where they were treated for dehydration.

During today’s visit, LPA was unable to interview R1, as they have since been relocated to another assisted living facility. LPA interviewed additional residents, and staff present during the incident. Residents interviewed did not report witnessing R1’s elopement and staff were unable to determine R1’s point of exit or elopement route. LPA obtained and reviewed R1’s Physician Report (LIC 602) dated 8/24/23, which indicates R1 is not able to leave facility unassisted.

Based on observation made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview conducted, a copy of this report, and appeal rights was left at the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
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 09/08/2023 02:18 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: BROOKDALE BREA
FACILITY NUMBER: 306003639

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2023
Section Cited
HSC
1569.2

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(c) "Care and supervision" means the facility assumes responsibility for... ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
This requirement is not met as evidence by;
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LPA obtained a copy of resident elopement drill conducted on 8/31/23. R1 was immediately assigned a 24-hour care companion as per facility plan of operations. R1 was relocated to another assited living facility on 9/02/23.
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Based on interviews and record review, LPA determined R1 was able elope from the facility without staff knowledge, resulting in hospitalization, which poses an immediately safety risk to persons 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.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
LIC809 (FAS) - (06/04)
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