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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221435
Report Date: 04/28/2022
Date Signed: 04/28/2022 01:55:32 PM


Document Has Been Signed on 04/28/2022 01:55 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:ADAM SYNCHEFFFACILITY TYPE:
740
ADDRESS:20801 DEVONSHIRE BLVDTELEPHONE:
(818) 341-2552
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:268CENSUS: 160DATE:
04/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Adam SyncheffTIME COMPLETED:
12:00 PM
NARRATIVE
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In conjunction to complaint control number 31-AS-20210401150014, upon LPA arrival at the facility, there was no administrator or designated staff to assist LPA immediately in addressing this complaint. LPA had to wait for a period of time (approximately 30-45mins) to get some assistance. Pursuant to 87405(a), there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section.

Based on facility's failure to comply, citation issued on the 809D.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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Document Has Been Signed on 04/28/2022 01:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/29/2022
Section Cited

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Administrator Qualifications and Duties: All facilities shall have a qualified and currently certified administratrator. When the administrator is not available, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management
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As POC, licensee will submit an updated LIC 308 to insure that there will be a designee to assist a licensing representative or any visitor while administrator is not available. Licensee will insure that this person will be qualified and competant enough to assist in the absence of the administrator.
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and administration of the facility as specified in this section. During visit on 4/28/22, administrator and or designee was not availble to assist LPA immediately as LPA had to wait for a period of time (approximately 30-45 mins), before given assistance.
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POC is due to licensing by 4/29/22

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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: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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