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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191221435
Report Date: 10/21/2022
Date Signed: 10/21/2022 02:02:21 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
04/06/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210406092145
FACILITY NAME:BROOKDALE CHATSWORTHFACILITY NUMBER:
191221435
ADMINISTRATOR:CHAPARYAN, LILITFACILITY TYPE:
740
ADDRESS:20801 DEVONSHIRE BLVDTELEPHONE:
(818) 341-2552
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:268CENSUS: 126DATE:
10/21/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Helen LeeTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident families were not informed about the incident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegation above. LPA met with facility staff and explained the reason for this visit.
Regarding the allegation above it is alleged that there was an incident on 4/1/21 where the facility kitchen became flooded due to a pipe bursting and food service was affected and facility did not notify resident families regarding the incident. Initial visit was conducted on 4/7/21 and interviews were conducted with the administrator regarding the allegation. During the visit the administrator admitted that they did not notify the families or Community Care Licensing of the incident. Based on the information obtained through previous interviews this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
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-20210406092145
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: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2022
Section Cited
CCR
87211(a)(2)
1
2
3
4
5
6
7
Reporting Requirements-Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or fax to licensing agency. This requirement was not met as evidenced:
1
2
3
4
5
6
7
Corrected before visit. New administrator has been hired since incident and self certification was given regarding reporting requirements.
8
9
10
11
12
13
14
Based on interviews conducted it was found the facility did not notify licensing or the families of the incident when the kitchen was flooded which affected food service in the facility which posed a potential personal rights violation to residents in care.
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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 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
04/06/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210406092145

FACILITY NAME:BROOKDALE CHATSWORTHFACILITY NUMBER:
191221435
ADMINISTRATOR:CHAPARYAN, LILITFACILITY TYPE:
740
ADDRESS:20801 DEVONSHIRE BLVDTELEPHONE:
(818) 341-2552
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:268CENSUS: DATE:
10/21/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility Kitchen is in disrepair
Residents are not provided with appropriate meals.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegations above. LPA met with facility staff and explained the reason for this visit.

Facility kitchen in disrepair
On 4/1/21 there was an incident where a pipe burst in a room above the kitchen area which flooded the kitchen area and impacted food services. Initial visit was conducted on 4/7/21 and interviews were conducted with staff. Information from the visit revealed that the kitchen was not usable and alternate arrangements had to be made regarding food service. Based on the information obtained through interviews this allegation is deemed Unsubstantiated. Facility had no way of knowing a pipe would burst that would flood the kitchen and quickly made arrangements to close the kitchen to get adequately prepared and arrange for food service for the residents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
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
Control Number 31-AS-20210406092145
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: 10/21/2022
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
Residents are not provided with appropriate meals.
It is alleged that while the kitchen was not open residents were not provided with appropriate meals. Initial visit was conducted on 4/7/21 and from there the administrator during that time was in contact with the facility LPA regarding the alternate food arrangements. Information obtained revealed that the facility hired a catering company to cater food for residents during the time the kitchen was shut down and residents were able to choose among an option of choices. During today's visit LPA conducted interviews with residents regarding that time period from 10-11am. Based on information obtained through interviews this allegation is deemed Unsubstantiated at this time. Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4