306003639-2-19-2025-22-AS-RMRT-DE33LH-20250219172047

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003639
Report Date: 02/19/2025
Date Signed: 02/19/2025 05:20:52 PM

Document Has Been Signed on 02/19/2025 05:20 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BROOKDALE BREA		FACILITY NUMBER:	306003639
ADMINISTRATOR/ DIRECTOR:	DANNY VERA		FACILITY TYPE:	740
ADDRESS:	285 W CENTRAL AVE		TELEPHONE:	(714) 671-7898
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY: 110	TOTAL ENROLLED CHILDREN: 0	CENSUS: 78	DATE:	02/19/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:30 PM
MET WITH:	Danny Vera, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

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Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an Unusual/ Special Incident Report (SIR) that was received in our office on February 19, 2025. LPA was greeted and granted entry into the facility by Executive Director, Danny Vera and explained the reason for the visit.

The SIR stated a resident had fallen and was taken to the hospital due to an unwitnessed fall. Resident has since returned to the community. Resident has a splint but was in good spirits and relayed to LPA the events that led to the fall. Resident was trying to, "not be a burden" and attempted to get up from his chair. Resident care plan is for full care and assistance from staff. LPA asked if he pressed his pendant but he did not. LPA also interviewed the resident's grandson who shared the details of the incident, as they were told to him by staff.

LPA spoke with Amber Lopez, Health & Wellness Director (HWD), who stated she is in constant communication with the family and speaks with the responsible party every Sunday. Family members visit the resident five days a week and are very involved. The resident has a history of falls and is receiving hospice care. After the last hospital visit, there is no change in the care plan since the resident already receives full care.

HWD stated the resident was found within a span of twenty minutes and the grandson and resident stated it was approximately fifteen minutes. It is not clear if the resident pressed his pendant for care assistance. Resident tries to be independent but is cognitively aware. Resident has a history of urinary tract infections (UTI) in which resident is being treated at present time.

LPA obtained the following documents from the resident file: Admissions Record, ID and Emergency Information Form, Physician's Report, Pre-appraisal and clinical notes. LPA also requested the staff schedule for the date of the fall, the staff roster and the resident roster.

(Continued on LIC 809-C)

Alisa Ortiz	TELEPHONE: (714) 287-4084
RoseMarie Ruppert	TELEPHONE: 714-703-2840
	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/19/2025

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(Continued from LIC 809)

A technical assistance (LIC 9102-TA) is being given to document a family care plan meeting for resident, family and care to explore options for fall prevention. Currently resident has hospice, a nurse practitioner and full care from facility.

Based on the interviews, file review and observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Danny Vera, Executive Director and a copy of the report, LIC 9102-TA and files reviewed (LIC 858) were given at the time of the visit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC809 (FAS) - (06/04)

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