191221435-7-13-2021-31-AS-EMIR-CCQLUQ-20220321090415

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191221435
Report Date: 07/13/2021
Date Signed: 07/13/2021 03:29:33 PM

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
06/25/2021 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20210625145528

FACILITY NAME:	BROOKDALE CHATSWORTH		FACILITY NUMBER:	191221435
ADMINISTRATOR:	DINA DAVIS		FACILITY TYPE:	740
ADDRESS:	20801 DEVONSHIRE BLVD		TELEPHONE:	(818) 341-2552
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	268	CENSUS: 117	DATE:	07/13/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Dina Davis		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility refused to accept resident back from skilled nursing facility

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegation above. LPA met with the administrator and explained the reason for this visit.
Regarding the allegation above it is alleged that facility was refusing to accept resident #1 (R1) back from a skilled nursing facility.
LPA previously conducted the initial visit on 6/28/21. During that visit LPA conducted interviews with the administrator. LPA obtained and reviewed copies of R1's facility file which included resident appraisal, admission paperwork, hospital paperwork, and incident reports. Since that visit LPA has conducted interviews with the social services director from the skilled nursing facility was at. LPA also interviewed R1's responsible person. At approximately 12:45 pm LPA interviewed the administrator again regarding the allegation. Information obtained from the previous visit and interviews reveal that R1 left the facility on 5/26/21 and was hospitalized. While at the hospital it was found that R1 had two prohibited health conditions that required R1 to be sent to a skilled nursing facility on 5/28/21. After approximately a month at the skilled nursing facility R1 was due to be discharged back

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

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-20210625145528

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: 07/13/2021

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

to the facility. However the administrator communicated with the skilled nursing facility and R1's family that R1 could not come back to the facility due to having a prohibited health condition. R1 needed to be receiving hospice services in order to be admitted back to the facility. As of 6/28/21 there was a referral for hospice but R1 had not been evaluated for hospice. On 7/1/21 R1 was evaluated for hospice by Kaiser and was deemed to not be qualified for hospice. A second evaluation was done by Kaiser and R1 was then approved for hospice. However Kaiser hospice never followed up with a hospice company or care plan. R1's family then found a hospice provider called So Cal Hospice. R1 was then admitted back to the facility under So Cal Hospice on 7/8/21. Based on the interviews conducted and records obtained from R1's skilled nursing facility this allegation is deemed Unsubstantiated at this time. R1 was admitted back to the facility once R1 obtained hospice services. Exit Interview conducted.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2