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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191221435
Report Date: 06/25/2021
Date Signed: 06/25/2021 02:04:09 PM

Substantiated


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
06/21/2021 and conducted by Evaluator Angelica Arambulo
COMPLAINT CONTROL NUMBER: 31-AS-20210621140710
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: 117DATE:
06/25/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Dina Davis, Gena Grundeis TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff are not responding to residents call button in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Arambulo conducted an iniitial 10 day visit regarding the above allegation. Director Dina Davis and Gena Grundels Associate Executive Director was informed about the purpose of the visit.

The Director was aware about the complaint and admitted to the incident happening, The fact is that a staff had left on a break and no one responded to residents call in a timely manner. Administrator did conduct an inservice training and is now trying a new method on call response to residents room. Based on the admission of the Director that they did not meet residents needs in a timely manner the allegation is therefore Substantiated.

Allegation cited on LIC9099D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Angelica ArambuloTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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 2
Control Number 31-AS-20210621140710
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: 06/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/25/2021
Section Cited
CCR
87468.1(A)(9)
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87468.1 (A)(9) Residents in all residential care facilities for the elderly shall have all of the following personal rights:


(9) To have communications to the licensee from their representatives answered promptly and appropriately.
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The Director has done an inservice training to promptly answer residents call. The call board will be placed in the reception area so it can be monitored.

Administrator submited a copy of the inservice training for all staff.
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This requirement is not met as evidence by: The staff failed to respond to residents call in a timely manner.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Angelica ArambuloTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2