Brookdale Anaheim

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff severely neglected resident resulted in hospitalization. Staff left resident in dirty diapers for extended periods of time. Illegal eviction. Staff failed to meet resident's needs.

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced continuation visit to the facility and to deliver the findings. LPA Rodriguez explained the purpose of today's visit, was greeted, by Executive Director (ED) Troy Byington. It was alleged that staff severely neglected resident resulted in hospitalization. 8 out of 8 resident interviews did not corroborate with the allegation by stating that facility staff are the care being provided are “great”. 4 resident interviews specified that facility will contact 911 if necessary, and if hospitalized, it was not due to staff neglect. 2 out of 2 staff interviews did not corroborate with the allegation. Per record review, there were no records of residents hospitalized due to staff neglect. Per observations, LPA observed that residents were taken care of, happy and engaging in their preferred activities. LPA was unable to obtain copies of records relevant to the allegation due to LPA Rodriguez making multiple attempts to conthe state’s words, verbatim · CDSS document, Nov 6, 2025 · control 22-AS-20210802145339

Allegation investigated: Resident's door is being locked resulting in resident services not being provided in a timely manner. Resident not being able to have adequate visitation. Resident not being fed in a timely manner. Resident's goods are being mishandled. Staff are handling resident in a rough manner when provided services.

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced continuation visit to the facility and to deliver the findings. LPA Rodriguez explained the purpose of today's visit, was greeted, by Executive Director (ED) Troy Byington. It was alleged that resident’s door is being locked resulting in resident services not being provided in a timely manner. 8 out of 8 resident interviews did not corroborate with the allegation by stating resident doors are locked per the discretion of the resident themselves, and also stated that that their rooms are locked due to personal preference, however were aware that staff have keys to access each room in case of an emergency. 2 out of 2 staff interviews did not corroborate with the allegation by also confirming that some residents have their rooms locked due to preference, and others have it unlocked, of which is also due to personal preferences, however, staff have keys to each resident rooms for emergency purposes. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 6, 2025 · control 22-AS-20210602084713

Allegation investigated: Facility served contaminated food to residents.

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility on October 13, 2025, to deliver findings regarding the above-mentioned allegation. Upon arrival, LPA Haddadin was greeted by Administrator (AD) Troy Boyington, who granted access to the facility. The purpose of the visit was explained. The allegation investigated was that the “Facility served contaminated food to residents.” Community Care Licensing (CCL) received a telephone report from the Orange County Health Care Agency (OCHCA). The complainant relayed information from the Public Health Nurse with the Communicable Disease Control Division, indicating that a resident (R1) at the facility tested positive for a foodborne illness identified as Salmonella Newport. LPA conducted interviews with five (5) residents and five (5) staff members. All interviewees denied the allegation. Residents interviewed stated they enjoyed the meals provided at the facility and had never become ill from the food sthe state’s words, verbatim · CDSS document, Oct 13, 2025 · control 22-AS-20251010101254

Allegation investigated: Food served to residents is not of good quality Staff do not treat resident with respect

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced continuation visit to the facility and to deliver the findings. LPA Rodriguez explained the purpose of today's visit, was greeted by Executive Director (ED) Troy Byington and Business Office Manager (BOM) Nicole Reyes. It was alleged that food served to residents is not of good quality. 7 out of 7 resident interviews did not corroborate with the allegation by stating that the meals being served are "good" and expressed satisfaction with the food quality and with the service of the kitchen staff. 1 out of 1 staff interview also did not corroborate with the allegation. Per record review, in 2024, there were two kitchen staff members (S1, S2) who were responsible for dining room duties, however S1 and S2 were terminated due to being observed not cooking meals thoroughly, not following recipes, serving meals late or cold, not engaging with residents, calling off, not cleaning kitchen regularly, not ensuring there wasthe state’s words, verbatim · CDSS document, Oct 13, 2025 · control 22-AS-20241031153522

Allegation investigated: Staff caused an injury to a resident in care Staff did not seek medical attention in a timely manner Staff did not prevent a resident from falling during a transfer

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as facility notes. Regarding the allegations that staff caused an injury to a resident in care, staff did not seek medical attention in a timely manner and staff did not prevent a resident from falling during a transfer, the investigation revealed the following: Five out of five staff stated Resident 1 (R1) did not have a fall nor injury occurring from a fall during transfer. Five out of five staff state there was no need to seek medical attention as resident has not sustained any injuries. Progress notes dated 10/29/2024-04/02/2025 do not show any falls or injuries sustained by the resident. Per Administrator, Residenthe state’s words, verbatim · CDSS document, Jul 30, 2025 · control 22-AS-20250417163319

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Unlawful eviction.

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of delivering the findings into the above allegation. LPA met with Executive Director (ED) Troy Byrington and explained the reason for the visit. During the course of the investigation, LPA successfully interviewed five out of six residents and three staff, and obtained pertinent documentation which includes Resident/Personnel Rosters, Personnel Reports, Staff Contacts, Facility Sketch, Eviction Notice dated January 21, 2025, Residents’ Face Sheets, Physician’s Report, Progress Note, Community Policy Violation Warnings dated November 14 & 18, 2024, Residency Agreement, Theft and Loss Policy and Procedure, and Resident Personal Property and Valuables. The investigation revealed the following: Unfoundedthe state’s words, verbatim · CDSS document, Jun 3, 2025 · control 22-AS-20250219113315

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff do not give resident privacy to get dressed Staff do not ensure that resident's hygiene needs are met Staff do not ensure that resident is accorded dignity in their relationship with staff or other persons

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facilty by Troy Byington, Executive Director and explained the reason for the visit. The Department received a complaint on 01/29/2025 and LPA Mendivil conducted the initial 10 day visit on 02/07/2025. During the visit LPA Mendivil obtained copies of staff schedule and housekeeping assignments as well as interviewed staff and residents. Regarding the allegations staff did not give resident privacy to get dressed, staff do not ensure that resident's hygiene needs are met, and staff do not ensure that resident is accorded dignity in their relationship with staff or other persons, the investigation revealed the following: Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 7, 2025 · control 22-AS-20250129104320

Allegation investigated: Staff do not ensure bathrooms are kept in clean, safe, sanitary conditions Facility bathroom floor is in disrepair Staff do not respond to signal system for residents timely manner

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed residents and staff as well as reviewed and obtained pertinent documentation such as extermination records. Regarding the allegations that staff do not respond to signal system for residents in a timely manner, facility bathroom floor is in disrepair, and staff do not ensure bathrooms are kept in clean, safe, sanitary conditions, the investigation revealed the following: Facility expectations for call button response times is 10-15 minutes. Four out of four staff and six out of seven residents state staff usually respond within those parameters. Seven out of seven residents state their needs are being met by facility staff. Facility does not have documentation of response tthe state’s words, verbatim · CDSS document, Jan 22, 2025 · control 22-AS-20230615102458

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff served contaminated food to residents

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director Troy Byington and explained the reason for the visit. LPA interviewed 7 residents and 5 staff members. LPA toured the kitchen and dining room. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the refrigerators and freezers were at the proper temperature. LPA observed the kitchen is clean and organized. LPA did not observe any contaminated or expired food in the kitchen. LPA observed lunch being served in the dining room. All 5 staff interviewed reported the food is delivered by a food distribution company and cooked using standard restaurant practices. All 5 staff interviewed denied serving contaminated food. 7 out of 7 residents interviewed reported they are happy with the food and had no issues. 2 out 7 residents reported ththe state’s words, verbatim · CDSS document, Oct 29, 2024 · control 22-AS-20241028142820

Allegation investigated: Staff did not properly address resident's multiple falls at facility.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Troy Byington, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that staff did not properly address resident's multiple falls at facility revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, Health and Wellness Director (HWD) Mink Medina, and witnesses, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Physician’s Report dated May 31, 2024, Facility Incident Reports for R1 dated September 1, 2024, to October 13, 2024, and R1’s Personal Service Plan dated October 13, 2024. It was alleged that R1 was taken to the hospital on October 10, 2024, after sustaining a fall at the facility and was diagnosed with a potential wrist fracture, this ithe state’s words, verbatim · CDSS document, Oct 18, 2024 · control 22-AS-20241014144704

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not provide resident's medical records to authorized representative

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on March 15, 2024. LPA Ramirez was allowed entry into the facility and met with Administrator (AD) Troy Byington. LPA explained the purpose of the visit. This Department has investigated the complaint alleging that staff did not provide resident's medical records to authorized representative. Resident 1 (R1) was admitted to the facility on April 17, 2020. Documents reviewed included the email request for R1’ medical records dated February 15, 2024. The email request was received by the facility AD on February 15, 2024. During the course of the interviews with staff, Staff 1 (S1) reported that resident medical requests are processed by the AD. During interviews with witnesses, Witness 1 (W1) reported that as of April 04, 2024 the records had not been received yet. During the course of the interviews AD reported that all requested documents werthe state’s words, verbatim · CDSS document, Jun 12, 2024 · control 22-AS-20240315145811

Allegation investigated: Staff stole resident's medication.

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of initiating the 10-day complaint investigation into the above allegation. LPA met with Executive Director (ED) Troy Byington and stated the purpose of the visit. During the course of the investigation, LPA interviewed one resident and five staff and pertinent documentation were obtained which includes: Resident Roster, Personnel Report Summary with staff's contact information, Face Sheet, Physician's Report, Medication List, Report of Suspected Dependendent Elder Abuse (SOC341), Photographs pertaining to Resident #1 (R1), and additional records pertaining to Staff #1 (S1). The investigation revealed the following: Regarding the allegation, Staff stole the resident's medication, it was alleged that on Thursday, May 30, 2024, S1 stole R1's opioid tablets, Hydrocodone-Acetaminophen. Per review of the Physician's Report dated April 12, 2024, R1 self-administers and stores their own medicationsthe state’s words, verbatim · CDSS document, Jun 7, 2024 · control 22-AS-20240604145438

Allegation investigated: Licensee does not ensure facility is free from roaches.

On this Day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Executive Director Troy Byington explained the reason for the visit. The Department received a complaint on 11/20/2023 and LPA Mendivil conducted the initial 10 day visit on 11/30/2023. During the visit LPA Mendivil interviewed staff and residents. LPA Mendivil obtained copies of pertinent documents such as pest control invoice, resident roster and pest sighting/evidence log. Regarding the allegation Licensee does not ensure facility is free from roaches, the investigation revealed the following: Per review of the pest sighting/evidence log there was a presence of pest on 11/15/2023, 11/24/2023 and 11/25/2023. During the visit on 11/30/2023 LPA Mendivil observed a small cockroach in an unoccupied room’s bathroom. Substantiatedthe state’s words, verbatim · CDSS document, Dec 21, 2023 · control 22-AS-20231120164159

Allegation investigated: Resident sustained pressure injury while in care

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings for the complaint investigation for the allegation listed above. LPA met with Executive Director Troy Byington and explained the reason for the visit. The investigation into the allegation revealed the following. Resident 1 (R1) returned from the skilled nursing facility on or around 4/14/2021. R1 was receiving visits from Home Health and Physical Therapy after their return to the facility. It was reported that R1 sustained a pressure injury while in care. A review of facility records shows R1 was diagnosed with a stage 2 pressure injury on 5/13/2021 by a medical professional and it was healed by 5/22/2021. 4 out of 4 Staff interviewed reported that R1 likes to be in a reclining chair all day and refuses to change positions or to be in their bed or any other chair during the day. R1’s family member reported that R1 likes to be in the reclining chair to watch TV and doesn’t want to be in bthe state’s words, verbatim · CDSS document, Dec 18, 2023 · control 22-AS-20210517141739

Allegation investigated: Resident was touched inappropriate by staff. Resident has fallen multiple times while in care. Staff are denying resident food. Staff are not checking on resident in a timely manner. Staff are not providing a safe environment for resident.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the complaint findings for the allegations listed above. LPA met with the Executive Director/Administrator Troy Byington and explained the reason for the visit. The investigation into the allegation,resident was touched inappropriate by staff, revealed the following. It was alleged that while taking Resident 1’s (R1) temperature staff inappropriately touched R1. R1’s responsible party reported that they never witnessed any inappropriate behavior from staff and R1 never mentioned to them any staff acting inappropriately. The Administrator reported that R1 never reported any issues to him, and he never witnessed any staff touching R1 inappropriately. The Administrator reported that when R1 moved in they mentioned that they would prefer female caregivers, so the facility accommodated R1. The Administrator reported that most caregivers are female so there was no issue with providing this for R1. Three outthe state’s words, verbatim · CDSS document, Nov 9, 2023 · control 22-AS-20210505114545

Allegation investigated: Staff are not providing the care necessary to meet resident's needs. Resident was not accorded dignity in her relationships with staff. Facility did not provide resident's representative with proper notification of rate increases.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with the Health and Wellness Director, Mink Medina and explained the reason for the visit. The investigation into the allegation, staff are not providing the care necessary to meet resident's needs, revealed the following. It was reported that Resident 1 (R1) fell on 9/14/20 and staff did not assist. Staff interviewed reported R1 did not fall in September. A review of special incidents reports for the facility for September 2020 do not show any incident reports for R1. It was alleged that R1 was left on the floor after the fall and staff did not assist R1. 4 out of 4 staff interviewed denied this report. R1 refused to be interviewed. It was reported that staff made R1 stand up without assistance during transfers which resulted in R1 falling on 9/14/20. 4 out of 4 staff interviewed denied this report. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 12, 2023 · control 22-AS-20200915080631

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.