191221435-2-23-2024-31-AS-MVAO-D2TQJG-20240226111244

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191221435
Report Date: 02/23/2024
Date Signed: 02/23/2024 09:28:45 AM

Unsubstantiated

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
11/06/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20231106160805

FACILITY NAME:	BROOKDALE CHATSWORTH		FACILITY NUMBER:	191221435
ADMINISTRATOR:	HELEN LEE		FACILITY TYPE:	740
ADDRESS:	20801 DEVONSHIRE BLVD		TELEPHONE:	(818) 341-2552
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	268	CENSUS: 126	DATE:	02/23/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Esmeralda Ornelas, Business Office Manager		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not respond to resident's call button in a timely manner resulting in a fall
Facility staff do not properly assist resident with toileting needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 09:00am, Licensing Program Analyst (LPA) Angela Panushkina, conducted an unannounced subsequent visit to deliver final findings. LPA met with the Business Office Manager and explained the reason for the visit.

During the initial visit made on 11/16/2023, interviews and record review were made. At 10:05am, LPA requested resident and staff roster. At 10:10am, LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Appraisal Needs and Services, Emergency Call Log, etc., relevant to the investigation. At approximately 10:20am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:30am – 1:30pm, LPA interviewed the Administrator, Health and Wellness Coordinator, four (4) staff, and ten (10) out of twelve (12) residents. Also, while interviewing a sample of 12 residents, LPA randomly tested resident’s pendant and emergency call buttons in bathrooms.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

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 2

Control Number 31-AS-20231106160805

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: 02/23/2024

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

Allegation: Facility staff did not respond to resident's call button in a timely manner resulting in a fall

To investigate this allegation while interviewing a sample of twelve (12) residents, LPA randomly tested resident’s pendant and emergency call buttons in their rooms. LPA conducted a random inspection of four (4) pendants and two (2) emergency call buttons, at Assisted Living (AL) Unit, and staff responded within a reasonable time. Interview with the Administrator and Health and Wellness Director revealed that the facility’s expectation for response time is 15 minutes. Moreover, interviews with four (4) staff members revealed that they respond to residents' call buttons immediately and if, for any reason, a staff member is not available to assist, they communicate with each other to make sure the call/page is being taking care of right away. In addition, interviews with ten (10) out of twelve (12) residents revealed that the staff always response within 5-10 minutes. Moreover, during the interview with R1, R1 expressed no concerns about the above allegation and informed LPA that the facility staff checks on him/her frequently. However, R1 forgets to press the pendant for an assistance before getting up from the bed and due to his/her medical condition R1's legs give out resulting R1 to fall. Based on interviews and review of the information received, allegation is deemed Unsubstantiated at this time.

Allegation: Facility staff do not properly assist resident with toileting needs

Interviews with the Administrator and four (4) staff revealed that all residents are being changed at least three (3) times per shift and or as needed. Moreover, LPA was informed that all residents are verbal, and when they ask for toileting needs, an immediate assistance is provided by the staff. LPA was able to interview ten (10) out of twelve (12) residents regarding this allegation. Ten (10) residents interviewed confirmed that they are assisted to the restroom, whenever they request to be taken and that has not been a concern. Based on interviews, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of this report signed an delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2