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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000831
Report Date: 11/24/2025
Date Signed: 11/24/2025 04:30:23 PM

Document Has Been Signed on 11/24/2025 04:30 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 GARDEN GROVEFACILITY NUMBER:
306000831
ADMINISTRATOR/
DIRECTOR:		JERI MILESFACILITY TYPE:
740
ADDRESS:10200 CHAPMAN AVETELEPHONE:
(714) 636-6453
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 140CENSUS: 119DATE:
11/24/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Brisseth Arrellano,Ted DawitTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on October 23, 2025, regarding Resident #1 (R1). LPA met with Administrator (AD) Brisseth Arrellano and Staff #1 (S1) Ted Dawit and explained the reason for today’s inspection.

During today’s inspection, LPA inspected the facility, interviewed AD, staff, and residents, and requested and reviewed copies of the resident roster, staff roster, R1’s Medical Records dated October 18, 2025, R1’s Physician’s Report dated October 14, 2025, R1’s Personal Service Plan dated September 13, 2025, and R1’s Personal Service Plan dated October 23, 2025.

Per the incident report received in the OCRO on October 23, 2025, on October 18, 2025, R1 had a fall at the facility and sustained a right toe fracture. LPA reviewed R1’s Medical Records dated October 18, 2025, which indicate R1 sustained a closed displaced fracture of the great toe. LPA interviewed AD who stated that R1 is a fall risk due to their multiple sclerosis which flares up and makes them unsteady, R1 does a good job keeping the facility informed of these flare ups and asking for extra care when necessary, and R1 has had multiple falls while at the facility but this is the first fracture R1 sustained. LPA reviewed R1’s Physician’s Report dated October 14, 2025, which indicates R1 has active progressive multiple sclerosis, Parkinson’s disease, and neuropathy, is non-ambulatory due to physical condition, but does not need assistance with bathing, dressing, eating, or toileting.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Sean Haddad
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BROOKDALE GARDEN GROVE
FACILITY NUMBER: 306000831
VISIT DATE: 11/24/2025
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LPA reviewed R1’s Personal Service Plan dated September 13, 2025, which indicates R1 is able to shower themselves but assistance was added for when R1 requests assistance, R1 is able to use the bathroom without assistance, escorts were temporarily added during a flare up of R1’s multiple sclerosis, and R1 is on the facility’s standard fall prevention plan. Per AD and facility staff, R1 was at a skilled nursing facility for over a month due to a multiple sclerosis flare up and returned to the facility on October 15, 2025, facility staff reassessed R1 to require additional care prior to R1 returning to the facility on October 15, 2025, and additional care was added to R1’s Personal Service Plan. LPA reviewed R1’s Personal Service Plan dated October 23, 2025, which documents the care services provided to R1 as of their return to the facility on October 15, 2025, and noted that assistance with emptying the commode and escorts were added. Per AD, R1 had a commode near their bed, R1 is able to get out of bed and to the commode on their own, but on October 18, 2025, R1 must have had a symptom of their multiple sclerosis and fallen on the way to the commode, injured their toe, and was taken to the hospital for treatment. Per facility staff, R1 has been receiving home health services three times a week for the toe injury and is not complaining of pain and R1’s room has been decluttered as clutter may have also played a role in R1’s fall. LPA interviewed R1 who raised no concerns over the care they receive at the facility. The information obtained did not corroborate lack of care and supervision causing R1’s fall as the facility regularly updated R1’s Personal Service Plans and added assistance where necessary to try to address R1’s chronic and evolving fall risk due to their multiple sclerosis.

There were no deficiencies observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Sean Haddad
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
LIC809 (FAS) - (06/04)
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