Inspection Reports for Brookdale Brookhurst

The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2025-10-03 alleging that staff did not seek timely medical attention for a resident in care.

The investigation substantiated the complaint, finding that the facility staff failed to ensure timely medical evaluation for Resident 1 despite visible severe bruising. Medical attention was only sought after the resident's daughter discovered the bruising later that evening.

The complaint was substantiated. The allegation that staff failed to seek timely medical attention for a resident was found valid based on photographic evidence, witness statements, and interviews. Six out of nine interviewees confirmed the bruising was identified only in the evening by the resident's daughter, and no timely medical care was provided prior to that.

The visit was a case management inspection conducted in conjunction with a continued complaint investigation regarding staffing levels at the facility.

The investigation found that the facility was inadequately staffed at the time of the incident, with staff responsible for excessive numbers of residents and insufficient supervision, particularly during the nocturnal shift in the Memory Care unit. The facility subsequently increased staffing levels following the incident.

The complaint investigation verified through interviews that seven out of nine interviewees reported inadequate staffing at the time of the incident, negatively affecting quality of care and supervision. The deficiency was substantiated and cited accordingly.

The inspection was conducted as a case management incident visit to follow up on an incident report regarding elopements of a memory care resident that occurred on October 1 and October 7, 2025.

The facility was found to have no health and safety issues during the inspection. The facility had addressed the issue of a delayed egress alert by making it more audible and adding an additional siren alert. The resident was safely returned within 20 minutes each time, and the facility followed proper elopement protocols including contacting law enforcement, family, and the resident's primary care physician. No deficiencies were cited at this time.

The visit was triggered by a complaint related to elopements of a memory care resident diagnosed with Alzheimer's. The complaint was investigated and found to be mitigated by the facility's corrective actions and monitoring.

The inspection was an unannounced complaint investigation visit triggered by complaints received on July 15, 2025, regarding staff not ensuring resident privacy, inappropriate removal of a resident's door, and use of a resident's room as a passageway to the bathroom.

The investigation found that the allegations regarding lack of privacy and inappropriate door removal were unsubstantiated, with residents and staff confirming efforts to accommodate privacy in shared suites. The allegation that a resident's room was used as a passageway to the bathroom was determined to be unfounded. No deficiencies were cited.

The complaint investigation was unannounced and conducted by Licensing Program Analyst Michael Tea. Allegations included staff not ensuring resident privacy, inappropriate removal of a resident's door, and use of a resident's room as a passageway to the bathroom. After interviews with residents and staff and review of records, the allegations were determined to be unsubstantiated or unfounded.

Licensing Program Analyst Michael Tea made an unannounced visit to conduct a continuation of the annual required inspection.

No deficiencies were noted during the inspection in the areas reviewed, including medication storage and administration, and resident care observations.

The visit was an unannounced annual required inspection conducted to evaluate compliance with licensing requirements for the facility.

The inspection found no deficiencies in the areas inspected during the visit. The facility was generally in compliance with regulations, with all resident and staff files containing required documentation. One emergency pendant in a resident bathroom did not work properly during testing, but staff responded within 15 minutes on a second test.

An unannounced complaint investigation visit was conducted following a complaint received on June 2, 2025, alleging that facility staff verbally threatened a resident with eviction and spread lies about a resident.

The investigation found no preponderance of evidence to substantiate the allegations. Interviews with residents and staff indicated that the alleged verbal threats and spreading of lies did not occur as claimed. No deficiencies were cited.

The complaint alleged that facility staff verbally threatened a resident with eviction and spread lies about a resident. The investigation determined these allegations to be unsubstantiated based on interviews and observations.

The inspection was a case management incident visit to follow up on an incident report regarding a medication error received by Community Care Licensing on May 21, 2025.

The facility did not ensure Resident 1 received assistance with self-administered medications as prescribed, resulting in a medication error. The facility was otherwise observed to be clean and organized with no other health and safety issues.

The visit was triggered by a complaint regarding a medication error involving Resident 1, submitted by Health and Wellness Director Suzette Paige, LVN. The deficiency was substantiated based on interview, document review, and observations.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-07-09 alleging that a resident sustained multiple pressure injuries due to neglect.

The investigation found that Resident 1 sustained multiple pressure injuries as a result of an unwitnessed fall and being left on the floor for approximately one to two days, posing an immediate risk to resident health and safety. The complaint was substantiated.

The complaint was substantiated. Resident 1 was found with multiple pressure injuries after an unwitnessed fall and being left on the floor for one to two days. The resident was admitted to UC Irvine Medical Center with multiple traumas and later passed away. Interviews revealed conflicting staff statements about resident checks.

An unannounced visit was conducted to deliver findings related to allegations of sexual abuse involving a resident and staff member, following a self-reported incident and subsequent investigation.

The investigation confirmed that Staff 1 engaged in inappropriate sexually explicit conversations and showed explicit images to Resident 1, repeatedly entered the resident's room without knocking, and violated the resident's personal rights. Staff 1 was terminated for violating facility harassment policies.

The visit was complaint-related due to allegations of sexual abuse by Staff 1 towards Resident 1. The complaint was substantiated based on interviews, police investigation, and facility records. Staff 1 admitted to inappropriate comments and showing explicit photos but denied any physical sexual acts. Staff 1 was terminated.

The visit was an unannounced case management inspection conducted by Licensing Program Analyst Michael Tea.

The Licensing Program Analyst amended reports LIC809 and LIC809C dated 08/12/2024 and reviewed the amended report with the Executive Director. An exit interview was conducted and copies of the reports were provided to the facility.

The inspection was a case management incident visit to follow up on an incident report received by Community Care Licensing on August 9, 2024, submitted by the Health and Wellness Director.

During the inspection, no health and safety concerns were observed. The facility was clean and organized, food supplies were adequately stocked, utilities were functioning, and medications and toxins were properly stored. No deficiencies were cited at this time.

The visit was an unannounced annual required inspection conducted to evaluate compliance with licensing regulations at the facility.

The facility was generally found to be in compliance with regulations, including operational safety systems, adequate resident accommodations, and proper medication administration. However, a deficiency was cited for accessible cleaning supplies and disinfectants in the memory care unit, posing a health and safety risk.

The inspection was an unannounced complaint investigation triggered by an allegation that lack of staff supervision resulted in a resident being left on the floor for an extended period of time.

The investigation substantiated that a resident (R1) was left on the floor for at least 24 hours after a fall resulting in a broken hip due to lack of staff supervision and failure to monitor the resident's whereabouts. Facility staff failed to use the Resident Meal Check Record properly, and the resident's pendant was out of reach. Immediate civil penalties were assessed. Another allegation regarding lack of care and supervision resulting in injury was unsubstantiated due to insufficient evidence.

The complaint was substantiated regarding lack of staff supervision resulting in a resident being left on the floor for an extended period, leading to injury. The allegation of lack of care and supervision resulting in injury was unsubstantiated due to insufficient evidence.

The visit was an unannounced complaint investigation conducted in response to a complaint received on 2024-04-16 alleging financial abuse at the facility.

The investigation determined that the alleged individual involved in the financial abuse was not employed by the facility. Based on interviews and record reviews, the complaint was found to be unfounded and was dismissed.

The complaint alleged financial abuse. After investigation including interviews with three staff members and one resident, and review of records, the allegation was deemed unfounded.

An unannounced complaint investigation was conducted due to an allegation that a lack of care and supervision resulted in a resident falling several times.

The investigation included interviews, a tour of the facility, and review of pertinent documents. The Department was unable to ascertain if the allegation occurred as reported and deemed the allegation unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that a lack of care and supervision resulted in a resident falling several times. The resident was newly diagnosed with Parkinson's disease and had episodes of dizziness and anxiety causing falls. Staff implemented safety checks and encouraged use of assistive devices. The allegation was found unsubstantiated.

An unannounced complaint investigation was conducted due to an allegation of lack of care and supervision resulting in an unstageable wound on a resident.

The investigation involved interviews and record reviews and found insufficient evidence to substantiate the allegation. The resident was discharged from the hospital without documented skin breakdown, wounds were first observed by facility staff on January 14, 2024, and the family expressed satisfaction with the care provided.

The complaint was unsubstantiated after investigation, which included interviews, document review, and observations. The allegation was that lack of care and supervision caused an unstageable wound, but evidence was insufficient to confirm this.

An unannounced complaint investigation was conducted due to an allegation that a resident sustained multiple falls due to lack of care and supervision.

The investigation found that staff responded appropriately to the resident's fall and that the resident was taken to the hospital for evaluation. Documentation and interviews did not corroborate the allegation, and there was insufficient evidence to prove or refute the claim, resulting in the allegation being deemed unsubstantiated.

The complaint alleged that a resident sustained multiple falls due to lack of care and supervision. The allegation was unsubstantiated after investigation, interviews, and documentation review.

An unannounced complaint investigation visit was conducted in response to allegations that staff do not respond to resident calls on the signal system and that the facility's signal system is not functioning properly.

The investigation included file reviews, interviews with residents and staff, and testing of the signal system pendants. Conflicting information was found regarding staff response times and signal system functionality. Due to lack of preponderance of evidence, the allegations were deemed unsubstantiated.

The complaint was unsubstantiated due to conflicting information and insufficient evidence to prove or refute the allegations.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-04-21 regarding staff response times, presence of insects, and availability of toiletries in public bathrooms.

The investigation found that staff response times to resident pendants varied between 10-45 minutes with mixed interview reports; no evidence of water contamination or malodor was found; insect presence was minimal and not substantiated by pest control records; toiletries were generally available though some interviews noted occasional shortages. Overall, allegations were deemed unsubstantiated or unfounded with no citations issued.

The complaint included allegations that staff were not responding timely to resident pendants, the facility had insects, and lacked toiletries in public bathrooms. The investigation included interviews, tours, and record reviews. The allegations were found to be unsubstantiated or unfounded based on observations and interviews.

An unannounced visit was conducted to investigate a complaint alleging that the facility did not have hot water.

The investigation substantiated the complaint that from 01/28/2023 to 02/04/2023, at least five resident rooms lacked hot water, posing a potential health and safety risk. Repairs were completed on 02/04/2023, and the facility notified residents and responsible parties while providing alternate rooms with hot water.

The complaint was substantiated based on evidence gathered through record reviews and interviews. The allegation was that the facility did not have hot water in parts of the facility, which was confirmed during the investigation.

Licensing Program Analyst Jim August conducted an unannounced visit for the purpose of conducting a required annual visit.

The facility was found to be clean and well maintained with no active COVID-19 cases. All required postings, sanitation supplies, emergency plans, and mitigation plans were observed and approved. No citations were noted during the visit.

An unannounced complaint investigation was conducted in response to allegations that a resident sustained an injury while in care and that staff did not seek medical attention in a timely manner.

The investigation found insufficient evidence to substantiate the allegations. No deficiencies were observed, no citations were issued, and the allegations were determined to be unsubstantiated.

The complaint involved a resident (R1) who allegedly sustained a burn injury from a coffee spill on October 16, 2021, and claims that staff did not seek timely medical attention. Interviews with staff and the resident revealed conflicting accounts, but ultimately the resident refused hospital care initially and the facility treated the injury. The resident was later hospitalized due to difficulty moving. The investigation concluded the allegations were unsubstantiated due to lack of preponderance of evidence.

The visit was an unannounced complaint investigation conducted to address multiple allegations including questionable death, residents left in soiled diapers for prolonged time, understaffing, inadequate care and supervision, presence of mold, and facility disrepair.

The investigation found insufficient evidence to substantiate most allegations such as mold, understaffing, and residents left in soiled diapers. However, the allegation that staff did not seek timely medical care for a resident was substantiated, resulting in a deficiency citation. No other deficiencies or citations were issued.

The complaint investigation was triggered by allegations including questionable death, residents left in soiled diapers for prolonged time, understaffing, inadequate care and supervision, mold, and disrepair. The allegation that staff did not seek timely medical care for resident 1 was substantiated. The other allegations were unsubstantiated.