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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306002962
Report Date: 06/11/2026
Date Signed: 06/11/2026 12:40:22 PM

Substantiated


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
06/01/2026 and conducted by Evaluator Michael Tea
COMPLAINT CONTROL NUMBER: 22-AS-20260601123459
FACILITY NAME:BROOKDALE BROOKHURSTFACILITY NUMBER:
306002962
ADMINISTRATOR:JOHN GOODWINFACILITY TYPE:
740
ADDRESS:15302 BROOKHURST STTELEPHONE:
(714) 775-6775
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:164CENSUS: 112DATE:
06/11/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:John GoodwinTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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- Staff did not distribute resident's medication as prescribed
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conduct a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. Executive Director (ED) John Goodwin arrived shortly to assist with the visit.

The department received a complaint on June 1, 2025, and LPA Tea conducted the initial 10-day visit on June 11, 2025. LPA Tea spoke to residents and facility staff and reviewed and collected pertinent documents and information.

It was alleged that staff did not distribute a resident's medication as prescribed. During the investigation, LPA reviewed records and conducted interviews with residents, staff, and facility management.

Interviews revealed that Resident 1 (R1) received medication intended for another resident. R1 reported
(Complaint Investigation continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026
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 3
Control Number 22-AS-20260601123459
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 BROOKHURST
FACILITY NUMBER: 306002962
VISIT DATE: 06/11/2026
NARRATIVE
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experiencing symptoms and was sent to the hospital for evaluation. ED Goodwin confirmed that Staff 1 (S1) self-reported the medication error and acknowledged that the wrong medication had been given to R1. Staff 2 (S2), who was present at the time, confirmed that S1 did not follow the facility's medication administration procedure and administered medication to the wrong resident. Resident 2 (R2), whose medication had been mistakenly given to R1, also confirmed that the error was discovered after questioning the medication they received.

Based on LPA’s interviews and information obtained during the investigation, the Department determined that staff failed to administer medication as prescribed. Therefore, the allegation mentioned above has been determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted with Executive Director (ED) John Goodwin and a copy of this report and appeal rights were provided to the facility
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260601123459
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 BROOKHURST
FACILITY NUMBER: 306002962
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2026
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall ... (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Facility will sign a statement of understanding for the regulation cited and will conduct an in-service training for medtech staff regarding proper medication administration procedures, including verifying the correct resident, medication, dosage, and time before administering medications. Training shall include review of the facility's medication error policy and procedures. Facility will submit proof of training, including the training materials, staff signatures, and date of completion, to LPA by POC due date by COB.
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Based on interviews, records reviewed, and observations made, the facility failed to ensure Resident 1 received proper assistance with self-administered medications when staff administered medication intended for another resident, resulting in a medication error. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026
LIC9099 (FAS) - (06/04)
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