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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002962
Report Date: 10/09/2025
Date Signed: 10/09/2025 05:05:06 PM

Document Has Been Signed on 10/09/2025 05:05 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 BROOKHURSTFACILITY NUMBER:
306002962
ADMINISTRATOR/
DIRECTOR:		JOHN GOODWINFACILITY TYPE:
740
ADDRESS:15302 BROOKHURST STTELEPHONE:
(714) 775-6775
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 164CENSUS: 114DATE:
10/09/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:John Goodwin and Suzette PaigeTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Michael Tea conducted a case management incident visit to follow up on an incident report received by Community Care Licensing Division (CCLD) on Oct 8, 2025, submitted by Health and Wellness Director (HWD) Suzette Paige. LPA was greeted and allowed entrance into the facility by Executive Director (ED) John Goodwin. LPA explained the reason for the visit.

The department received an incident report regarding elopements of a memory care resident, Resident 1 (R1) that happened on October 1, 2025 and October 7, 2025. During the visit, LPA and ED Goodwin toured the facility and inspected Clare Bridge Memory Care unit and R1's room. LPA conducted a health and safety check on R1 and observed no health and safety issues. Based on LPA's observation and review of records, despite R1 having a diagnosis of Alzheimer's, R1 is very cognitive, high functioning and very alert. LPA toured and observed the rest of the facility and found no health and safety issues. LPA requested and reviewed copies of R1’s resident file.

LPA Tea spoke to staff and management regarding R1's care and the elopements. One of the delayed egress on the doors in the memory care unit in which R1 has exited out of, has an alert that is not loud enough for staff to hear. The alert does go to the front desk and 2nd floor of the facility, and staff has caught the alerts in time during each elopement. Currently the facility has fixed the annunciator alert for the delayed egress in the memory care unit to be more audible and louder and added additional siren alert as of yesterday, Oct 8, 2025. R1 is very quick and can run fast but each elopement they were able to bring him back to the facility within in a short matter of time, no more than 20 mins and less than a mile away from the facility. The facility did follow elopement protocols and contacted local law enforcement. They contacted the family and R1's primary care physician. Facility was was able to redirect him to the facility and ensure that he

(Report continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BROOKDALE BROOKHURST
FACILITY NUMBER: 306002962
VISIT DATE: 10/09/2025
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was safe. Facility management believes R1 needs a higher level of care. With proper mitigation, the facility has been keeping a close observation on R1 and since the last elopement the facility has had the family hire a one to one personal caregiver from 7:00 AM to 7:00 PM for R1. After the hours of the personal caregiver, the facility has assigned a facility caregiver staff to be with R1 till bedtime and monitoring throughout the night.

Based on the observations made during today’s inspection, no deficiencies are being cited at this time.

An exit interview was conducted with Executive Director John Goodwin and Health and Wellness Director Suzette Paige and a copy of this report was provided at exit.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC809 (FAS) - (06/04)
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