<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003639
Report Date: 07/19/2024
Date Signed: 07/19/2024 11:42:12 AM


Document Has Been Signed on 07/19/2024 11:42 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 BREAFACILITY NUMBER:
306003639
ADMINISTRATOR:SARAH DEVOREFACILITY TYPE:
740
ADDRESS:285 W CENTRAL AVETELEPHONE:
(714) 671-7898
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:110CENSUS: 85DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator, Danny VeraTIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 7/19/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Administrator, Danny Vera who was informed of the purpose of the visit. The facility has a fire clearance for 104 non-ambulatory residents of which six (6) may be bedridden. The facility also has an approved hospice waiver for 20 residents and LPA was informed there are seven (7) residents currently on hospice.

LPA toured the facility with Administrator Vera and observed the facility is made up of a two-story building designated for assisted living. During the tour, LPA observed the facility has a large dining room, kitchen, courtyard, and several activity rooms. LPA toured the kitchen and observed food was stored in a safe and healthful manner. The facility met Departmental requirements for a 2-day supply of perishable food and 7-day supply of non-perishable food items. LPA observed a cork board in the kitchen identifying residents with special dietary needs/requests. LPA toured a sample of resident rooms and observed rooms had the required furniture and lighting. Resident bathrooms had toilet paper, towels and soap readily available. LPA was informed medications are secured in medication carts, only accessible to authorized personnel such as wellness nurses and medication technicians. LPA observed fire alarm systems and carbon monoxide detectors throughout the building along with charged fire extinguishers serviced on 4/2/2024. Indoor and outdoor passageways are free of obstruction. The courtyard offers shaded seating for the residents. No bodies of water were observed on the premises. LPA was informed the facility offers outings once a week and recreational activities throughout the week. LPA reviewed random staff and resident files. Resident files reviewed had signed admission agreements and updated Physician's Reports (LIC 602A). Staff files reviewed had a criminal record clearance and a valid first aid/CPR certification.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted where this report was reviewed and provided to Administrator Vera.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1