306003639-5-30-2024-22-AS-AJLO-D6CTG2-20240618144225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003639
Report Date: 05/30/2024
Date Signed: 05/30/2024 01:49:30 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
04/19/2024 and conducted by Evaluator Dwayne L Mason

COMPLAINT CONTROL NUMBER: 22-AS-20240419101753

FACILITY NAME:	BROOKDALE BREA		FACILITY NUMBER:	306003639
ADMINISTRATOR:	SARAH DEVORE		FACILITY TYPE:	740
ADDRESS:	285 W CENTRAL AVE		TELEPHONE:	(714) 671-7898
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY:	110	CENSUS: 89	DATE:	05/30/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Tierny Wilburn - Interim Executive Director		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Facility staff did not provide itemized statements of charges to resident

INVESTIGATION FINDINGS:

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This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by Receptionist Maritza Mancha.

LPA met with Interim Executive Director (IED), Tierny Wilburn and Business Office Manager (BOM), Lisabelle Paranda and explained the nature of the inspection.

The department received a complaint on 4/19/2024 alleging facility staff did not provide itemized statements of charges to Resident. The Reporting Party (RP) disclosed to the LPA that they had made requests for their itemized monthly statements but had not received them. During the investigation, the department interviewed staff and residents in care.

(continued from LIC9099)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

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-20240419101753

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BROOKDALE BREA	FACILITY NUMBER: 306003639
	VISIT DATE: 05/30/2024

NARRATIVE

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(continued from LIC9099)

On 4/26/2024 LPA obtained copies of the following files for six residents: Residency Agreements, Pre-Placement Appraisals, Personal Service Assessments, Physician Reports, Physician's Diet Orders, Preferred Food Lists, Account Histories and a recent monthly statement.

On 5/9/2024 LPA returned to the facility and conducted interviews with staff who stated that residents’ itemized monthly statements are mailed to the facility and placed in residents’ individual mailboxes. LPA interviewed Resident 1 who corroborated the allegation. Interviews were conducted with Residents 2, 3, 4 and 5 who stated they have no issues receiving their itemized monthly statements.

Due to conflicting information received during interviews conducted, LPA was unable to determine if facility did not provide itemized monthly statement to resident. Based on interviews and record review, LPA determined itemized monthly statements are mailed to the facility and placed in resident mailboxes; facility maintains copies of residents’ itemized monthly statements and will provide them to resident’s upon request. Based on interviews conducted and records reviewed there is insufficient evidence to support the allegation. Although the allegation(s) may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and this report was reviewed with Interim Executive Director and Business Office Manager and a copy of this LIC-9099 was provided to the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC9099 (FAS) - (06/04)

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