Brookdale Brea

Allegation investigated: Resident developed Stage 4 pressure injury due to lack of care/supervision.

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by the receptionist at 2:55pm. LPA was introduced to the new Executive Director (ED) Laurie Galal, and explained the purpose of the visit. During the course of the investigation, the Department interviewed staff and witnesses; and subpoenaed and reviewed Hospice and Hospital medical records. The investigation revealed the following: Per Resident #1’s (R1)'s Medical Assessment, dated November 10, 2025, R1 has a diagnosis of necrosis of right femur. Prior to moving into Brookdale Brea on January 30, 2026, R1 resided at a skilled nursing facility. R1 resided at Brookdale Brea from January 30, 2026 – March 8, 2026. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) Resident #1 (R1) was sent to the hospital on February 5, 2026, and returned on February 9, 2026, with a suprapubic catheter; which was maintained by home health. R1 was admitted to hospice services and per hospice documentation, received services for pain management and comfort care. An updated medical assessment from February 9, 2026, documented R1 has a history of skin condition or breakdown. Beginning on February 16, 2026, R1 received hospice services once a week for wound care. Per interview with facility staff, the facility requested additional wound care for a pressure injury on the sacrum; since the wound care provided to R1 was not sufficient. On February 24, 2026, R1 had an additional assessment by Wound Pros. R1 was sent out to the hospital on March 2, 2026, due to the pressure injury not healing. R1 returned to the facility on March 5, 2026, and the facility continued to follow the Primary Care Provider’s (PCP) orders until March 8, 2026. On March 8, 2026, the Health and Wellness Director (HWD) sent R1 to the hospital since the pressure injury showed no improvement. HWD stated they did not receive hospice documentation regarding the pressure injury being stage 3 until the HWD made the decision to send the resident out on March 8, 2026. Hospice Provider Notes to the facility, dated February 26, 2026, stated the pressure injury was stage 3. The resident did not return to the facility and resided at Kaiser Permanente until March 23, 2026. While hospitalized, it was reported the pressure injury measured 12 cm in length on the sacrum and unstageable right heel injury measured 3 cm. LPA interviewed three of three staff members. Three of three staff denied the allegation and stated the facility continuously monitored the resident and communicated with the hospice agency to request additional wound care. Two of three staff who provided direct care to the resident stated they continued to speak with the hospice agency and felt they were unresponsive. The facility decided to send the resident out on March 8, 2026 due to insufficient wound care being provided. LPA attempted to interview the hospice agency three different times. LPA interviewed two of three residents. Two of three residents stated they were happy with the quality of care provided and denied the allegation of neglect and lack of supervision. LPA interviewed one witness who denied the allegation that Resident developed Stage 4 pressure injury due to lack of care/supervision. The witness stated that the hospice agency was to provide wound care and that the facility was communicative and followed orders. (Continued on LIC 9099-C1) (Continued from LIC 9099-C) Based on LPA’s interviews, observations and document review, the allegation that Resident developed Stage 4 pressure injury due to lack of care/supervision is Unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with ED Laurie Galal and a copy of this report and LIC 811 was provided to the facility.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 22-AS-20260311144516

Allegation investigated: Facility did not meet the food service requirements causing residents to feel ill.

On May 21, 2026, Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose of initiating the complaint investigation into the above allegation. LPA met with Business Office Manager Lisabelle Paranda and Health & Wellness Coordinator Monica De Luna and explained the reason for the visit. During the course of the investigation, LPA toured the kitchen and observed one meal service and interviewed eight residents and five staff. Copies of records were also obtained for review: Resident Roster, Personnel Report, Staff Contact Information, Face Sheets, Progress Notes, Physician's Reports, Incident Reports, Employee Timecards, Weekly Menu, written correspondence, and Infection Control Plan. The investigation revealed the following: Regarding the allegation, Facility did not meet the food service requirements causing residents to feel ill, it is alleged that residents experienced symptoms of foodborne illness such as diarrhea and vomiting caused by the food. During the visit, LPA observed a meal service approximately 12:23pm. Unsubstantiated According to the posted food menu and observations, residents were served mixed green salad, country fried steak or shrimp scampi as the main entree, option of roasted brussel sprouts, corn o'brien, white rice, or au gratin potatoes as the accompaniments, and a choice of dessert (pistachio ice cream, fresh diced pears/apples, or reduced sugar frosted lemon cake). LPA toured the kitchen and storage rooms accompanied by Executive Chef Andres Alvarez. LPA observed the kitchen to be well maintained, clean, sanitary, and in good repair. Kitchen staff were observed following procedures which protect the safety, nutritional values in food storage, preparation, and service. LPA observed all kitchen staff engaged in food preparation or serving, washed their hands and complied with sanitation practices. LPA also observed housekeeping staff cleaning each units and common areas during the visit. An ample supply of Personal Protective Equipment (PPE) was observed in the medication room on the second floor. Based on the interviews, five out of five staff confirmed many residents and staff experienced symptoms of contagious illness and remained at home. Four out of five staff denied that the illness was caused by the food while one staff contributed their symptoms after having several meals prepared by the facility. Eight of eight residents confirmed experiencing flu symptoms such as diarrhea, vomiting, nausea, and/or dizziness. However, seven of the eight residents denied being related to food but a "germ" or a "virus." Based on the review of the incident reports submitted to the Department, a total of 30 residents were affected from April 28, 2026 to May 7, 2026. Facility reported the GI outbreak to the California Department of Health (CDPH) via email starting April 29, 2026 once facility determined that the second case was not an isolated incident. Based on the interviews with five staff and eight residents, all confirmed that facility followed infection control practices such as hand hygiene, cleaning and disinfection, wore PPE (gloves, masks, and gowns). The investigation revealed that the facility complied with infection control practices, ensured a clean and safe care environment, and reported the incidents to the Department and CDPH timely. There was insufficient corroborating evidence to prove that illness was caused by the food. Therefore, based on the observations made, interviews which were conducted, and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Facility did not meet the food service requirements causing residents to feel ill is deemed UNSUBSTANTIATED. An exit interview was conducted with Business Office Manager Lisabelle Paranda and Health & Wellness Coordinator Monica De Luna, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, May 21, 2026 · control 22-AS-20260519150602

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by the Concierge and met with Executive Director (ED) Logan Harrison. LPA explained the purpose of the visit. The facility has a fire clearance for 104 non-ambulatory; of which six may be bedridden. The facility has a hospice waiver for twenty. Currently the facility has a census of sixty-nine residents; of which one is bedridden. Currently there are seven residents on hospice. During the visit, LPA toured the facility and observed the press button to automatically open the front doors was out-of-order. LPA reviewed paperwork submitted by the Maintenance Director for a purchase order (PO) number and the quotation was submitted and a PO number was provided. One of two elevators was also out-of-order and LPA observed the elevator was being repaired. At end of visit both elevators were operational. LPA obtained paperwork from the Maintenance Director and the fire alarms were tested by an outside vendor on 1/27/2026. The fire sprinkler system was also tested by the same vendor on 1/21/2026 and passed inspection. LPA observed fire extinguishers throughout the facility and they were charged and inspected on April 8. 2026. Evacuation chairs were observed on stairwell/stairways. The facility conducted its last fire drill on April 15, 2026 on consecutive days with different working shifts. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. A First Aid Kit and manual are available with the required elements. The PUB 475 Poster is posted in the entryway. LPA inspected the hot water in four of four resident apartments. The hot water temperatures ranged between 112.8 to 114.1 degrees Fahrenheit. (Continued on LIC 809-C) (Continued from LIC 809) LPA toured the dining room which was clean and there were no odors detected. The daily and monthly menus were observed. Kitchen fire extinguishers were inspected on April 8, 2026. Sharps and knives were secured and modified diets were posted on the kitchen wall. The refrigerator and freezer had temperature logs and were at the required temperatures. The Dining Services Manager showed LPA the emergency supply list that is maintained.. Emergency supplies were in storage. The facility retained two-days of perishables and seven-days of non-perishable food items. While touring, LPA observed the facility was a comfortable 76 degrees Fahrenheit. Laundry rooms were clean and chemicals and cleaning supplies were secured. Washers and dryers were operational. The courtyard is maintained and shaded seating areas were observed. There were no hazards or obstructions blocking pathways. LPA observed residents doing chair exercise in the library and a group activity in the second floor activity room. LPA reviewed five of five staff training and fingerprint records and reviewed six of six resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on November 18, 2027. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Logan Harrison, Executive Director and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, May 1, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to follow-up on an Unusual Incident Report received by the Regional Office. LPA was greeted and granted entry by the receptionist. LPA met with Danny Vera, Executive Director, and explained the purpose of the visit. LPA requested the following: Resident and Staff Rosters, and items from Resident #1 (R1)'s file. The items include copies of: Identification and Emergency Information, Physician's Report, Pre-appraisal Information, and Resident Care Theft and Loss Policy. LPA interviewed Resident #1 (R1) regarding the incident that occurred on July 14, 2025. The incident report stated a staff member intentionally crushed R1's finger. On July 15, 2025 Emergency Medical Services (EMS) transported to the local hospital, local law enforcement were called and an Elder Abuse Report (SOC 341) was filed with the Regional Office and the Long Term Care Ombudsman. The Responsible Party was also notified. R1 returned to the community on the same day with no new orders. X-rays revealed there were no fractures. LPA interviewed Resident #1 and three of three staff. R1 recounted the incident and stated it was not a finger, that it was the entire right hand. Upon staff interviews, three of three staff stated that the day of the incident, R1 acknowledged it was an accident and the ring finger of the right hand was evaluated. The alleged caregiver had apologized to R1, had immediately called the MedTech and the Health and Wellness Director visited R1 with medical options for care. The next day, R1 contacted local law enforcement and asked to be transported to the hospital for further evaluation. (Continued on LIC 809-C) (Continued from LIC 809) Based on the observations, record review and interviews made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Danny Vera, Executive Director and a copy of the report and files reviewed (LIC 811) were given at the time of the visit.the state’s words, verbatim · CDSS document, Jul 29, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by the Receptionist. During today’s visit, LPA met with Danny Vera, Executive Director (ED). The facility is a two story building with an approved fire clearance of one-hundred four non-ambulatory residents; of which six may be bedridden. The facility currently has a census of seventy-eight residents in care. The facility is approved for a hospice waiver of twenty residents and there are five residents receiving hospice services. During today’s visit, LPA toured the facility with ED Vera and inspected the physical plant, including but not limited to testing all smoke detectors and testing hot water temperatures in four of four resident bathrooms. The hot water temperatures measured between 109.4 and 113.7 degrees Fahrenheit. LPA tested a resident bathroom pull cord and staff responded under five minutes. Resident bathrooms had non-skid mats and grab bars. All smoke detectors were operational and tested on November 4, 2024 by an outside vendor. A fire system alarm inspection is scheduled for May 2025. The fire extinguishers were charged and were serviced on April 8, 2025. The facility’s last fire drill was conducted on February 12, 2025. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA toured the kitchen and observed resident modified diets posted for line staff. Freezer and refrigerators were at the proper temperatures. Residents were observed in the dining room at 11:30am and had complimentary things to say about the lunch entree of the day. (Continued on LIC 809-C) (Continued on LIC 809) LPA observed the courtyard garden which is also maintained by residents. There were covered seating areas for the residents to enjoy the garden. The second floor had newly installed fitness eliptica and bike with a view of the courtyard garden. Residents were observed participating in a Skip Bo card activity and other residents were doing chair exercises in the library. LPA observed washers and dryers in use on the first floor. There were no hazards or obstructions in passageways and outdoors. All stairwells had evacuation chairs. LPA observed medication storage and reviewed the centrally stored medications. Per review residents' medications were being given as prescribed. A First Aid Kit was observed in the medication room with the required elements. LPA observed the PUB 475 See Something, Say Something poster. LPA reviewed four of four staff training and fingerprint records and reviewed seven of seven resident records.LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on November 14 2025. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Danny Vera, Executive Director and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Apr 29, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an Unusual/ Special Incident Report (SIR) that was received in our office on February 19, 2025. LPA was greeted and granted entry into the facility by Executive Director, Danny Vera and explained the reason for the visit. The SIR stated a resident had fallen and was taken to the hospital due to an unwitnessed fall. Resident has since returned to the community. Resident has a splint but was in good spirits and relayed to LPA the events that led to the fall. Resident was trying to, "not be a burden" and attempted to get up from his chair. Resident care plan is for full care and assistance from staff. LPA asked if he pressed his pendant but he did not. LPA also interviewed the resident's grandson who shared the details of the incident, as they were told to him by staff. LPA spoke with Amber Lopez, Health & Wellness Director (HWD), who stated she is in constant communication with the family and speaks with the responsible party every Sunday. Family members visit the resident five days a week and are very involved. The resident has a history of falls and is receiving hospice care. After the last hospital visit, there is no change in the care plan since the resident already receives full care. HWD stated the resident was found within a span of twenty minutes and the grandson and resident stated it was approximately fifteen minutes. It is not clear if the resident pressed his pendant for care assistance. Resident tries to be independent but is cognitively aware. Resident has a history of urinary tract infections (UTI) in which resident is being treated at present time. LPA obtained the following documents from the resident file: Admissions Record, ID and Emergency Information Form, Physician's Report, Pre-appraisal and clinical notes. LPA also requested the staff schedule for the date of the fall, the staff roster and the resident roster. (Continued on LIC 809-C) (Continued from LIC 809) A technical assistance (LIC 9102-TA) is being given to document a family care plan meeting for resident, family and care to explore options for fall prevention. Currently resident has hospice, a nurse practitioner and full care from facility. Based on the interviews, file review and observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Danny Vera, Executive Director and a copy of the report, LIC 9102-TA and files reviewed (LIC 858) were given at the time of the visit.the state’s words, verbatim · CDSS document, Feb 19, 2025

Allegation investigated: Staff mismanaged resident's medication

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the 10-day visit to begin the investigation into the allegation listed above. LPA was greeted and granted entry by staff. LPA met with Executive Director Danny Vera and explained the reason for the visit. LPA interviewed staff. LPA requested documents such as medication administration records, needs and care plans and physician reports. The investigation revealed the following. Resident 1 (R1) went to the hospital on October 17, 2024 and was discharged on October 22, 2024. On the hospital discharge paperwork R1 was ordered to continue taking Clopidogrel 75mg (Plavix). According to the Medication Administration Record (MAR) the medication was not added until December 2024. Staff reported they wanted to verify the order because hosptial discharge paperwork is not accepted by the Pharmacy and they do not accept it as an official order for medication. R1 was handling their own medication prior to the hospital visit from October 17 through October 22, 2024. The hospital contacted the facility and informed them R1 could not manage their own medications. R1 and their family agreed. Substantiated When the facility took control of R1's medication on October 25, 2024 Clopidogrel 75mg (Plavix) was part of the inventory of R1's medication. According to the MAR for R1 they only received Clopidogrel 75mg (Plavix) from December 20, 2024 to December 26, 2024. R1's Clopidogrel 75mg (Plavix) was stored securely in the facility's medication room. The facility did verify the order for the medication but not until December 20, 2024. The discharge paperwork from the hospital is signed by the doctor and is an official order. Based on the evidence gathered the preponderance of evidence standard has been met; therefore, the above allegation is substantiated. See LIC9099-D for cited deficiency per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.the state’s words, verbatim · CDSS document, Dec 31, 2024 · control 22-AS-20241224130741

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Jan 2, 2025

(16) To receive or reject medical care or other services. This requirement was not met as evidenced by, a record review shows R1 was prescribed Clopidogrel 75mg (Plavix) on October 22, 2024 but it was not administrered to R1 until December 20, 2024. This poses an immediate health and safety risk to the resident.the state’s words, verbatim · CDSS document, Dec 31, 2024

Plan of correction: Licensee agrees to train staff on CCR 87468.1 personal rights of residents in all facilities and submit proof of training to the LPA by the POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an Unusual Incident Report that was received in our office on October 25, 2024. LPA was greeted and granted entry into the facility by the concierge at 2:30 PM. During today’s visit, LPA met with Danny Vera, Administrator (AD). LPA requested Resident #1's (R1) file and Staff #1's (S1) personnel record for review. There are no reports on file from Brea PD. LPA interviewed R1 at 2:45 PM regarding the incident that occurred on October 21, 2024 at 6:30 PM. R1 shared the events that happened that evening regarding a male staff member, S1 assisting R1 from the commode to bed. Upon transfer, R1 lost strength in her knees and S1 held her against the bed to support her and called for assistance from a second staff member, Staff #2 (S2). In the few minutes it took for S2 to arrive, R1 felt something hard pressed against her back. After S2 assisted S1 with the bed transfer and left, S1 mentioned to R1 that there was wetness on his leg to which R1 replied the wetness came from S1. LPA interviewed Staff #1 at 3:40 PM and showed the LPA the items carried in his scrubs pockets on his left side. Items include: small hand sanitizer, small contacts solution bottle, an eye dropper and a walkie-talkie radio. LPA inquired where the wetness was on his leg during the incident and S1 showed a spot just above the left knee. Staff #2 was not present for interview at time of visit. The facility submitted the Unusual Incident Report, the Mandated Reporter Abuse Form (SOC 341) and cross reported to Brea Police Department (PD) (Case #2410-2021), the Long Term Care Ombudsman (LTCO) and Community Care Licensing (CCL). Brea PD interviewed resident and involved staff members and the LTCO interviewed the facility. (Continued on LIC 809-C) (Continued from LIC 809) Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Danny Vera, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Nov 1, 2024

Type of visit: Required - 1 Year

On 7/19/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Administrator, Danny Vera who was informed of the purpose of the visit. The facility has a fire clearance for 104 non-ambulatory residents of which six (6) may be bedridden. The facility also has an approved hospice waiver for 20 residents and LPA was informed there are seven (7) residents currently on hospice. LPA toured the facility with Administrator Vera and observed the facility is made up of a two-story building designated for assisted living. During the tour, LPA observed the facility has a large dining room, kitchen, courtyard, and several activity rooms. LPA toured the kitchen and observed food was stored in a safe and healthful manner. The facility met Departmental requirements for a 2-day supply of perishable food and 7-day supply of non-perishable food items. LPA observed a cork board in the kitchen identifying residents with special dietary needs/requests. LPA toured a sample of resident rooms and observed rooms had the required furniture and lighting. Resident bathrooms had toilet paper, towels and soap readily available. LPA was informed medications are secured in medication carts, only accessible to authorized personnel such as wellness nurses and medication technicians. LPA observed fire alarm systems and carbon monoxide detectors throughout the building along with charged fire extinguishers serviced on 4/2/2024. Indoor and outdoor passageways are free of obstruction. The courtyard offers shaded seating for the residents. No bodies of water were observed on the premises. LPA was informed the facility offers outings once a week and recreational activities throughout the week. LPA reviewed random staff and resident files. Resident files reviewed had signed admission agreements and updated Physician's Reports (LIC 602A). Staff files reviewed had a criminal record clearance and a valid first aid/CPR certification. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted where this report was reviewed and provided to Administrator Vera.the state’s words, verbatim · CDSS document, Jul 19, 2024

Allegation investigated: Facility staff did not provide itemized statements of charges to resident

This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by Receptionist Maritza Mancha. LPA met with Interim Executive Director (IED), Tierny Wilburn and Business Office Manager (BOM), Lisabelle Paranda and explained the nature of the inspection. The department received a complaint on 4/19/2024 alleging facility staff did not provide itemized statements of charges to Resident. The Reporting Party (RP) disclosed to the LPA that they had made requests for their itemized monthly statements but had not received them. During the investigation, the department interviewed staff and residents in care. (continued from LIC9099) Unsubstantiated (continued from LIC9099) On 4/26/2024 LPA obtained copies of the following files for six residents: Residency Agreements, Pre-Placement Appraisals, Personal Service Assessments, Physician Reports, Physician's Diet Orders, Preferred Food Lists, Account Histories and a recent monthly statement. On 5/9/2024 LPA returned to the facility and conducted interviews with staff who stated that residents’ itemized monthly statements are mailed to the facility and placed in residents’ individual mailboxes. LPA interviewed Resident 1 who corroborated the allegation. Interviews were conducted with Residents 2, 3, 4 and 5 who stated they have no issues receiving their itemized monthly statements. Due to conflicting information received during interviews conducted, LPA was unable to determine if facility did not provide itemized monthly statement to resident. Based on interviews and record review, LPA determined itemized monthly statements are mailed to the facility and placed in resident mailboxes; facility maintains copies of residents’ itemized monthly statements and will provide them to resident’s upon request. Based on interviews conducted and records reviewed there is insufficient evidence to support the allegation. Although the allegation(s) may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and this report was reviewed with Interim Executive Director and Business Office Manager and a copy of this LIC-9099 was provided to the facility.the state’s words, verbatim · CDSS document, May 30, 2024 · control 22-AS-20240419101753