<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221435
Report Date: 10/20/2021
Date Signed: 10/22/2021 08:14:34 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BROOKDALE CHATSWORTHFACILITY NUMBER:
191221435
ADMINISTRATOR:DINA DAVISFACILITY TYPE:
740
ADDRESS:20801 DEVONSHIRE BLVDTELEPHONE:
(818) 341-2552
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:268CENSUS: 121DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator-Dina Davis TIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 9:30 AM, Licensing Program Analysts (LPAs) Joscelyn Martinez and Melissa Ruiz conducted an unannounced annual inspection at the facility mentioned above. Upon arrival, LPAs were greeted by the front desk staff and later met with Executive Care Director Gena Grundeis and later met with administrator Dina Davis.

A physical tour was conducted at 9:52 am and observed the following: Infection control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Upon entrance, staff took LPAs’ temperature and was asked to sign-in the visitor’s log. All trash cans were observed to have closed tight fitting lids. Facility has sufficient PPE supplies for more than 30 days. Food Inspection: LPAs observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps, cleaning supplies and medications are centrally stored in a locked area. Smoke detectors/carbon monoxide are located throughout the facility and are hardwired. A fire alarm initial test was conducted by LAFD on 08/25/21 and passed. Fire extinguishers were observed throughout the facility and were serviced on 04/26/21. Common Areas: These include the dining areas, theater room, TV areas, activity rooms, and library. All common areas were observed to be cleaned and properly furnished. Facility maintains a comfortable temperature of 75.0 F. Resident rooms: A random selection of rooms were inspected. All bedrooms are properly furnished, cleaned and have appropriate bedding and linens. Bathrooms: The hot water temperature measured between 118.5-118.7 degrees Fahrenheit. Outside areas: LPAs toured the outside area of the facility. LPAs observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water. No deficiencies cited. An exit interview was conducted. A copy of this report was provided.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1