191221435-11-4-2021-31-AS-NGID-CBRW55-20220218155835

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191221435
Report Date: 11/04/2021
Date Signed: 11/04/2021 01:41:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/29/2021 and conducted by Evaluator Melissa Ruiz

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20211029110057

FACILITY NAME:	BROOKDALE CHATSWORTH		FACILITY NUMBER:	191221435
ADMINISTRATOR:	DINA DAVIS		FACILITY TYPE:	740
ADDRESS:	20801 DEVONSHIRE BLVD		TELEPHONE:	(818) 341-2552
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	268	CENSUS: 122	DATE:	11/04/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Gena Grundeis - Assistant Executive Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff lost track of resident's medication.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 10:30 AM, Licensing Program Analyst Melissa Ruiz arrived at the facility mentioned above to conduct an unannounced complaint investigation. Upon entrance, LPA was greeted and screened for infection control by the front desk staff and later met with Assistant Executive Director Gena Grundeis. The purpose of this visit was explained, entrance interview conducted.

It is alleged that staff lost track of resident’s medication.

To conduct this investigation, LPA conducted interviews and reviewed relevant documents. According to the interviews conducted with the assistant executive director and two staff, they were aware medication was delivered for resident (R1); however, they remained unsure about the delivery date.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 31-AS-20211029110057

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BROOKDALE CHATSWORTH	FACILITY NUMBER: 191221435
	VISIT DATE: 11/04/2021

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
26
27
28
29
30
31
32

Interviews also reveal that the medication was given to the medication technician and was kept locked away in the medication room. An interview with R1 conducted at 11:40 am also confirms that the medication was handed to the medication technician. Interviews conducted and R1’s personal service plan revealed R1 administers their own medication, therefore R1 should have been notified it was delivered. Additionally, LPA reviewed the medication log and the mail log, and no entry was made for R1’s medication on either log during the time frame of delivery. Due to the information mentioned above, this allegation is deemed substantiated at this time.

Deficiencies were issued per CA code of Regulations Title 22. See 809D's included with this report. Appeal rights issued. Exit interview conducted.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 31-AS-20211029110057

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BROOKDALE CHATSWORTH	FACILITY NUMBER: 191221435
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/06/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465(a)(5) Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Assistant Executive Director will meet with staff and implement a log sheet for medication recieved for the front desk and for the medical technician to ensure medication arrived at facility is traceable.
	8 9 10 11 12 13 14	Based on document review and interviews conducted, staff did not log the arrival of medication which poses an immediate health and safety risk to residents in care since resident was unaware of its arrival and location.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/29/2021 and conducted by Evaluator Melissa Ruiz

COMPLAINT CONTROL NUMBER: 31-AS-20211029110057

FACILITY NAME:	BROOKDALE CHATSWORTH		FACILITY NUMBER:	191221435
ADMINISTRATOR:	DINA DAVIS		FACILITY TYPE:	740
ADDRESS:	20801 DEVONSHIRE BLVD		TELEPHONE:	(818) 341-2552
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	268	CENSUS: 122	DATE:	11/04/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Gena Grundeis - Assistant Executive Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Medication not administered as prescribed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Allegation: Medication not administered as prescribed.

At 10:50 am, Licensing Program Analyst (LPA) Melissa Ruiz reviewed R1’s personal service plan, dated and signed on 05/04/21. The personal service plan states, “Resident self-manages their medications including self-administering, ordering, coordination and safe storage.” LPA also interviewed R1 at 11:40 am, and R1 stated they administer their own medication.

According to R1’s testimony and the personal service plan reviewed, R1 administers their own medication therefore this allegation is deemed unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4