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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402583
Report Date: 01/10/2025
Date Signed: 01/10/2025 07:28:02 PM

Document Has Been Signed on 01/10/2025 07:28 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:BROOKDALE NORTH EUCLIDFACILITY NUMBER:
366402583
ADMINISTRATOR/
DIRECTOR:		LISA TOFACILITY TYPE:
740
ADDRESS:1031 N EUCLID AVETELEPHONE:
(909) 391-2622
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 140TOTAL ENROLLED CHILDREN: 0CENSUS: 79DATE:
01/10/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:45 PM
MET WITH: Lisa To Executive Director TIME VISIT/
INSPECTION COMPLETED:
07:40 PM
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
Licensing Program Analyst (LPA) Bernadette Allen made unannounced case management visit regarding a self-reported incident on the relocation of (19) nineteen residents from Brookdale Ocean House facility number 198-204758 due to mandatory evacuation orders from Fire Advisory. LPA Allen met with Marcos Ramos Business Office Manager who was informed of the purpose of the visit. At 7:00PM Lisa To Executive Director arrived and she was informed of the purpose of the visit.

During the visit, LPA Allen conducted a health and safety check and there were no concerns observed. LPA reviewed and obtained resident and staff rosters for both facilities.

Per interview with Marcos Ramos and Helen Lee, (19) nineteen residents have been relocated from Brookdale Ocean House which (2) two residents were in route to the facility. During the visit there were (17) seventeen residents accounted for. The facility has sufficient beds, hygiene supplies, beddings, linens, and everyone has a designated room.

The dining room is large enough to accommodate all residents. The kitchen has sufficient two-day perishable and seven-day non-perishable food supplies. LPA observed Medications and MARs for the residents transferred and residents’ files can be accessed electronically. The residents transferred are ambulatory per Lisa To- Executive director.

There is sufficient staffing available to provide care for residents of both facilities. It has been verified that a routine Fire inspection and testing was completed on August 1, 2024, and a fire & disaster drill was conducted on December 12, 2024. Lisa To confirmed that all families and/or responsible parties have been notified about the relocation.
Karen ClemonsTELEPHONE: (951) 248-0349
Bernadette AllenTELEPHONE: 951-897-2618
DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: BROOKDALE NORTH EUCLID
FACILITY NUMBER: 366402583
VISIT DATE: 01/10/2025
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
26
27
28
29
30
31
32
Lisa To has confirmed residents from Brookdale Ocean House residents will not share rooms with Brookdale North Euclid residents. LPA Allen also observed Brookdale Ocean House residents are one (1) to (2) two persons to a room.

An exit interview was conducted, and a copy of this report was provided Lisa To- Executive director at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2