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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000831
Report Date: 05/05/2026
Date Signed: 05/05/2026 12:32:27 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/19/2021 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210119160607
FACILITY NAME:BROOKDALE GARDEN GROVEFACILITY NUMBER:
306000831
ADMINISTRATOR:ROBERT JAKINIFACILITY TYPE:
740
ADDRESS:10200 CHAPMAN AVETELEPHONE:
(714) 636-6453
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY:140CENSUS: 115DATE:
05/05/2026
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Brisseth ArrellanoTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Staff did not provide appropriate care and supervision to resident.
INVESTIGATION FINDINGS:
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On 05/05/2026, Licensing Program Analyst (LPA) Pang Lee conducted a Microsoft Teams meeting with Facility Designated Administrator (FDA) Brisseth Arrellano, for the purpose of delivering complaint findings for the allegations above. A brief interview with FDA Arrellano.

It was alleged that staff did not provide appropriate care and supervision to resident. During the course of the investigation, the Department conducted interviews with facility staff, residents in care, and a resident’s responsible party. Based on interviews with five out of five residents, all reported no concerns regarding care and supervision. All residents also stated that they feel safe living in the facility. LPA Lee attempted to interview Resident 1 (R1); however, R1 is no longer residing at the facility and was not able to contact R1’s responsible party.

CONTINUED LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20210119160607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GARDEN GROVE
FACILITY NUMBER: 306000831
VISIT DATE: 05/05/2026
NARRATIVE
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 In an interview with another resident’s responsible party, it was stated that staff are helpful and check on their mother several times a day, and that they “couldn’t ask for better care.” Based on a review of records, there was no documentation indicating that R1 was hospitalized and or any incident reports. LPA also attempted to obtain additional records/information regarding the allegation; however, further details could not be obtained from the facility, and current facility staff were not working at the time of the alleged incident. Based on interviews and records reviewed during the investigation, LPA Lee was unable to corroborate the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did nor did not occur, therefore, the allegation is unsubstantiated. An Exit Interview was conducted with (FDA) Arrellano and a copy of this report was provided to the facility via email. A certified copy will be sent to the facility mailing address.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2