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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003639
Report Date: 05/24/2022
Date Signed: 05/24/2022 01:47:59 PM


Document Has Been Signed on 05/24/2022 01:47 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: 67DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Sarah DevoreTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year Annual inspection, with an emphasis on Infection Control due to the COVID-19 pandemic. LPA Martinez was screened upon entry into the facility. LPA met with Executive Director Sarah Devore and reason for the visit was explained. Administrator Certificate expires on 1/26/2023.

LPA toured the facility with Executive Director Devore. Facility has 67 Residents in care during today's visit with 6 Residents receiving Hospice care. Facility is only Assisted Living. LPA observed kitchen, Bistro, Library, Activity Room, and Hair Salon, LPA observed Residents relaxing, walking around and/or finishing up lunch. Residents appeared happy and well taken care of. Facility appears clean and sanitary. Resident rooms have the required elements as well as common bathrooms were stocked with soap/sanitizer/paper towels. Rooms are all single occupancy. Visitors are screened upon entry. LPA observed the screening/sanitizing station at the entrance of the facility. Facility checks temperature and has a sign-in log sheet. Facility takes resident and staff temperatures daily and documents. First Aid kit has all required items. Mitigation Plan has been approved. Facility has emergency evacuation chairs at the top of stairwells. LPA observed an ample supply of emergency food and water. LPA observed multiple outside visitation areas. LPA observed the Medication Room and facility uses electronic medical records for medication management. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed select resident files during the visit and files are up to date including emergency information. Most residents and staff are vaccinated for COVID-19. All required Department posters were observed.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report will be emailed to ED.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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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