Brookdale Irvine

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced visit to the facility to deliver the findings. LPA Rodriguez explained the purpose of today's visit and was greeted by business office manager (BOM) Sharin Belanger. It was alleged that facility staff did not handle resident properly resulting in injury. Six interviews were conducted with staff and residents, of which all six interviews did not corroborate with the allegation. Interviews conducted with resident 1 (R1) stated that staff are friendly and helpful, and verified that staff never handled R1 in a way that resulted in injury. Per record review, R1 is not diagnosed with dementia or cognitive impairment and during R1's hospitalization, R1 was placed on blood thinners, and was informed that R1 would be more prone to bruising. Record review also revealed that R1 requires assistance getting to and from the wheelchair, to which R1 confirmed that staff will utilize a gait belt, and denied of staff grabbing R1'sRead the full finding— CDSS inspection report, June 11, 2025 · control 22-AS-20230817142044

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced visit to the facility to continue the investigation and to deliver the findings. LPA Rodriguez explained the purpose of today's visit and was greeted by business office manager (BOM) Sharin Belanger. It was alleged that staff did not respond to resident's call button in a timely manner. LPA Rodriguez conducted a total of 10 resident interviews of which all 10 resident interviews did not corroborate with the allegation. It was verified by residents that staff do respond to a resident's call button. 1 out of 1 staff interview did not corroborate with the allegation by stating that the target response time when a call button is pressed, is to be no longer than 30 minutes. Per record review of the pendant report, in the month of April and May, staff responded to a resident's call button between 7 to 24 minutes. During the tour of the facility, LPA conducted random call button checks, to which staff responded within 3Read the full finding— CDSS inspection report, June 11, 2025 · control 22-AS-20240503163000

Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility to initiate a 10-Day complaint investigation into the above allegation. LPA met with Business Office Manager Sharin Belanger. LPA spoke to Executive Director (ED) Shannon Howell via telephone. LPA conducted a walk-through of the facility, obtained copies of the Staff schedule and Resident roster and other pertinent documents. LPA also conducted interviews with the Executive Director via telephone, Business Office Manager, Health & Wellness Director, 2 staff and 13 residents. Regarding allegation that Facility failed to provide reasonable accommodation to a resident's needs & preferences, the investigation revealed the following: On 07/28/2024, Resident 1 (R1) was intoxicated and had a fall hitting R1's head. On 07/30/2024, facility received a doctor's order for R1 that states "Can Drink NO Alcohol...Patient should be in an Alcohol Rehab Program". On 07/30/2024, R1, R1's Emergency Contact, ED, HealtRead the full finding— CDSS inspection report, January 15, 2025 · control 22-AS-20250109160520

Licensing Program Analyst (LPA) Michael Tea made an unannounced complaint visit on this day to deliver findings for the allegation mentioned above. LPA met with Executive Director (ED) Shannon Howell. It was alleged that facility staff did not follow admission agreement. During the investigation LPA interviewed residents and staff; checked resident files; and reviewed resident invoices; personal service plans; assessments; staff progress notes; and daily shift reports. The investigation determined the following: On the signed Admission Agreement on page 2 Section I Clause B “Personal Service Plan,” states “Prior to moving in and periodically throughout your residency, we will use a personal service assessment to determine the personal services you require. The personal service assessment will be used to develop your Personal Service Plan. The results of the assessment, our method for evaluating your personal care needs, and the cost of providing the additional services (the “Personal SRead the full finding— CDSS inspection report, December 13, 2024 · control 22-AS-20240515084741

This unannounced investigation inspection by Licensing Program Analysts (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPAs arrived at the facility and were greeted by facility staff. LPA met with Iris Nunez, Resident Care Coordinator, and explained the nature of the inspection. The department received a complaint on 6/19/2024 stating the facility lacks staff. During the investigation, the Department interviewed Executive Director, staff and residents in care. (continued on LIC9099-C) Substantiated— CDSS inspection report, November 8, 2024 · control 22-AS-20240619132458

Licensing Program Analyst (LPA) Michael Tea made an unannounced complaint visit on this day to deliver findings for the allegation mentioned above. LPA met with Executive Director (ED) Shannon Howell. It was alleged that facility staff charged for services not rendered. During the investigation LPA interviewed residents and staff; checked resident files; and reviewed resident invoices; personal service plans; assessments; staff progress notes; and daily shift reports. The investigation determined the following: The facility was supposed to provide medication; dressing and grooming; and showering or bathing services which were discussed in the personal service plan and assessment summary and admission agreement of Resident 1 (R1). (Continued on LIC9099C) **THIS IS AN AMENDED REPORT** UnsubstantiatedRead the full finding— CDSS inspection report, September 13, 2024 · control 22-AS-20240515084741

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA met with Sharrin Belenger, Bussiness Office Manager and explained the nature of the visit. Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegation. Findings are based upon this investigation which included interviews conducted and copies of pertinent documents obtained (hospital records, SOC341 and residents facility file). It is alleged that resident sustained an injury from a fall while in care. Hospital records revealed that the attending physician indicated per patient's DPOA with whom he had a lengthy discussion over the telephone who informed doctor that the patient has had multiple hospitalizations since December 2019 initially multiple times at Mission Regional Medical Center followed by multiple recent hospitalizations at Hoag HospitRead the full finding— CDSS inspection report, April 30, 2024 · control 22-AS-20200730163608

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted by Executive Director (ED) Shannon Howell. It was alleged that staff did not give proper notice to resident's designated representative of rate increases. LPA conducted an interview with the reporting party (RP) who stated that the current ED explained everything to RP regarding rate increases, of which RP also verified that the notice was received and provided timely. It was alleged that staff did not give resident's designated representative explanations for rate increases. LPA conducted an interview with RP and staff 1 (S1), of which both interviews verified that explanations were provided regarding the increases. Both interviews stated that resident 1 (R1) would order "tray service" to their room and was getting charged every time R1 utilized tray service. UnsubstantiatedRead the full finding— CDSS inspection report, October 13, 2023 · control 22-AS-20230726101433

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation(s). LPA met with Business Office Manager Sharin Belanger and Administrator (AD) Shannon Howell and explained the reason for today’s inspection. The investigation into the allegations of facility allows resident's medication supply to run out and lack of staffing revealed the following: During the course of the investigation, LPAs inspected the facility, interviewed AD, 3 staff, and 10 residents, and obtained and reviewed copies of the Resident Roster, Staff Schedule, Physician’s Report for Residential Care Facilities for the Elderly (Physician’s Report) for 13 residents, Medication Administration Records (MAR) for 10 residents, Weights and Vitals Summaries for 10 residents, the facility’s Diagnosis Report, an email dated 07/10/23 from AD to a prospective resident, and Hoag Hospital IrvinRead the full finding— CDSS inspection report, October 9, 2023 · control 22-AS-20200610155521

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegations received on 07/24/23. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Shannon Howell. LPA explained the reason for the visit. On today’s visit LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation that facility has pests, the following was revealed: Seven of eight individuals interviewed denied the allegation. The remaining individual reported seen a rat in the the lounge area during mid-July. During the course of the investigation LPA reviewed documents including the Ecolab Service Inspection Reports for June and July 2023. Two of two Ecolab Service Reports state the following: "Inspected and treated selected areas. Pest Activity Found." During the initial visit on 07/26/23 LPA toured the kitchen and observed rat traps on the corners of the kitcRead the full finding— CDSS inspection report, September 11, 2023 · control 22-AS-20230724102229

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver findings for the complaint received on 12/20/23. LPA arrived at the facility and explained the purpose of today’s visit and was greeted by executive director (ED) Shannon Howell. The complaint was investigated by the Department which involved interviews and pertinent records review. It is alleged that the staff failed to obtain medical care in a timely manner for resident who sustained serious injures after an unwitnessed fall. The investigation revealed that on December 15, 2022, resident (R1) sustained a fall in their room and was not checked on until December 17, 2022. Staff (S1) even stated being “too busy” to check R1 because R1 was “always independent”. R1 personal service assessment plan dated April 5, 2022, stated that R1 has sustained a total of three falls within the past twelve months. SubstantiatedRead the full finding— CDSS inspection report, August 3, 2023 · control 22-AS-20221220140629

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver the findings for the above allegation. LPA met with Executive Director (ED) Shannon Howell and stated the purpose of the visit. On 10/4/22, an initial 10-day visit was conducted. The complaint was investigated by the Department. Findings are based upon this investigation which included record reviews and interviews. It is alleged that facility staff sexually assaulted resident in care. The investigation revealed that on September 13, 2022, resident (R1) reported that caregiver (S1) touched R1’s vaginal area in a sexual manner. It was later revealed that R1 discovered that S1 was making sexual advances with another resident, which led R1 to report the incidents to Executive Director. SubstantiatedRead the full finding— CDSS inspection report, June 2, 2023 · control 22-AS-20221003131319

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver the findings for the complaint recieved on 2/17/23. LPA De Perio was greeted by West Division Operations Specialist who is also acting as Executive Director (ED) Lilit Mnatsakanyan and stated the purpose of the visit. For today's visit, there are a total of 80 residents in care of which 2 are on hospice. (SEE LIC9099-C) Unsubstantiated— CDSS inspection report, March 16, 2023 · control 22-AS-20230217165102

Licensing Program Analyst (LPA) Celine De Perio made an unannounced complaint visit to the facility to initiate the 10-day visit for the complaint received on 2/21/23 and to deliver the findings. LPA De Perio was greeted by West Division Operations Specialist who is also acting as Executive Director (ED) Lilit Mnatsakanyan and stated the purpose of the visit. For today's visit, there are a total of 82 residents in care of which 3 are on hospice. LPA De Perio conducted interviews with staff and residents, and reviewed and requested copies of the pertinent records. This department has investigated the complaint alleging that residents are not being accorded with dignity and respect. UnsubstantiatedRead the full finding— CDSS inspection report, March 3, 2023 · control 22-AS-20230221120641

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with Operations Specialist/Executive Director-Lilit Mnatsakanyan and stated the purpose of this visit, which was to deliver the final findings for the complaint received on 11/15/22 against this facility. For today's visit, there are a total of 84 residents in care of which 4 residents are on hospice. See LIC9099-C. Unsubstantiated— CDSS inspection report, January 23, 2023 · control 22-AS-20221115104657

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. Operations Specialist Lilit Mnatsakanyan arrived during the visit. During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as shower schedule and facility daily assignments. Regarding the allegation that staff are not meeting resident's hygiene needs, the investigation revealed the following: Per Resident 1's (R1) Personal Service Plan dated 03/01/2021, resident is scheduled for showers two times a week on Tuesdays and Saturdays. Review of shift reports dated 12/03/2021 and 12/08/2021 indicated R1 received 2 showers on a Wednesday and a Friday. Facility is unable to provide additional shift reports for December. Daily assignment sheets indicated residentRead the full finding— CDSS inspection report, January 19, 2023 · control 22-AS-20211216143011

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. Operations Specialist Lilit Mnatsakanyan arrived during 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 pendant call log. Regarding the allegation that staff did not respond to resident's call for assistance in a timely manner, the investigation revealed the following: Staff interviewed indicate kitchen staff do not have pagers therefore would be unable to hear any pendant calls or pages regarding resident calls or needs. During the investigation, LPA reviewed pendant call logs from 12/03/2021-12/10/2021. LPA observed 102 staff responses were between 23-44 minutes. Administrator indicated expected response time was under 15 minutes and staff interviewedRead the full finding— CDSS inspection report, January 19, 2023 · control 22-AS-20211207162734

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an 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, reviewed staff training records and interviewed staff. Regarding the allegation that staff are not properly trained, the investigation revealed the following: Five out of five staff training records reviewed contained proof of current staff training. Training included but not limited to: Dementia training, Alzheimer's Disease, Postural Supports, Restricted Conditions and Personal Rights. Five out of five staff interviewed stated receiving training from the facility. Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility. UnfoundeRead the full finding— CDSS inspection report, January 19, 2023 · control 22-AS-20220506152646