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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221435
Report Date: 10/10/2023
Date Signed: 10/10/2023 12:40:26 PM


Document Has Been Signed on 10/10/2023 12:40 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: 128DATE:
10/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anchirza Concepcion, Helath and Wellness Director TIME COMPLETED:
11:30 AM
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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 that occurred on 05/17/23. LPA met with the Health & Wellness Directior (HWD) and explained the reason for the visit.

LPA conducted physical plant tour at around 10:30am, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations.



During the initial Case Management Visit, conducted on 05/24/23, LPA requested copy of facility documents relevant to the investigation and interviewed staff between 10:45am to 12:10pm.

Interview, conducted with the Executive Director (ED), on 05/24/23, revealed that R1’s family reported an incident wherein R1’s prescribed pain medications (3 pills) were stolen by Staff #1 (S1) on 05/17/23 at 7:26am from R1’s room. LPA was also able to review a copy of a video footage related to the incident. Moreover, LPA was 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 pain medications from R1’s room without a permission. ED informed LPA that right after the interview with S1, at 12:40pm, a police report was filed.

On 10/09/23, LPA reviewed documents (all required training transcripts for S1 from 2021 to 2023, S1's fingerprint clearance and association to this facility, etc.) obtained during the initial visit, including SOC341, Incident Report and a Police Report. Based on interviews, record review and LPA's inspection it was found that ED reported the incident appropriately and S1's employment was terminated, immediately.

During today's visit HWD and ED informed LPA that all staff completed in-service training regarding Theft and Loss Prevention, Elder Abuse, etc. LPA was also informed that all residents medication is kept locked.
No deficiency will be cited at this time. Exit interview conducted and copy of this report signed and delivered

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
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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