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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221435
Report Date: 05/24/2023
Date Signed: 05/24/2023 03:12:35 PM


Document Has Been Signed on 05/24/2023 03:12 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: DATE:
05/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Helen Lee, Executive Director TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced case management visit at this facility to follow up on the incident occurred on 05/17/23. LPA met with an Executive Director (ED) and explained the reason for the visit.

LPA conducted physical plant tour at around 10:30am, requested copy of facility documents relevant to the investigation at 10:40am and interviewed staff between 10:45am to 12:10pm. LPA also reviewed records between 12:20pm to 1:00pm.

During today’s interview with ED, LPA was informed that R1’s family reported an incident wherein R1’s prescribed narcotic medications (3 pills) were stolen by Staff #1 (S1) on 05/17/23 at 7:26am from R1’s room. LPA was also informed that on 05/18/23 at 8:00am S1 was suspended by ED, pending investigation. During the investigation conducted by ED, on 05/18/23 at 12:00pm, S1 confirmed that he/she took R1’s narcotic medications from R1’s room without a permission. S1 also assured ED that no other wrong/inappropriate actions towards other residents were made. ED informed LPA that right after the interview with S1 a police report was filed, at 12:40pm.

In addition, Regional Office (RO) received two more incident reports (SOC341 included) which occurred on 05/05/23 and 05/10/23. During today’s interview, LPA was informed that ED was not aware of those two (2) incidents until after S1 was suspended from the facility. On 05/19/23, R2 reported to ED that on 05/10/23 he/she willingly loaned money to S1. Moreover, on 05/22/23 a report came from another resident R3 stating that on 05/05/23 he/she also willingly loaned money to S1. ED attempted to file a police report for both incidents, however, due to voluntary nature of loaning money is considered a civil matter.

Lastly, LPA reviewed the facility staff’s records and observed the staff are up to date with the required yearly training.
There are no deficiencies to report at this time. Exit interview conducted. Copy of this report delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
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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