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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221435
Report Date: 12/07/2022
Date Signed: 12/07/2022 04:43:02 PM


Document Has Been Signed on 12/07/2022 04:43 PM - It Cannot Be Edited

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:HELEN LEEFACILITY TYPE:
740
ADDRESS:20801 DEVONSHIRE BLVDTELEPHONE:
(818) 341-2552
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:268CENSUS: 127DATE:
12/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Helen LeeTIME COMPLETED:
04:55 PM
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On 12/07/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced investigation visit. During this visit LPA tested the pull cords at the facility. LPA tested a random selection of rooms which included rooms number 148, 224, 107, N12, 310, and 155B. LPA waited in the room or near the room until a staff responded to the pull cord. LPA observed that staff responded by going into the resident's room within five to ten minutes.LPA observed that pull cords were functional and operational. Residents stated that they frequently use a signal pendant necklace if they need assistance since they always carry it with them. Additionally residents stated they prefer to call the front desk for assistance instead of using the pull cords .During the physical walk through LPA observed the front desk receiving calls from residents requesting assistance and staff will use walkie-talkies to request staff to the designated rooms.

No deficiencies cited. Report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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