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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191221435
Report Date: 04/17/2024
Date Signed: 04/17/2024 05:36:25 PM

Substantiated


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
04/16/2024 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20240416105120
FACILITY NAME:BROOKDALE CHATSWORTHFACILITY NUMBER:
191221435
ADMINISTRATOR:DANNY VERAFACILITY TYPE:
740
ADDRESS:20801 DEVONSHIRE BLVDTELEPHONE:
(818) 341-2552
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:268CENSUS: 129DATE:
04/17/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Danny Vera, Executive Director TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff does not respond to resident’s pendant call.
Staff not maintaining resident’s hygiene.
INVESTIGATION FINDINGS:
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At 10:00am, Licensing Program Analysts (LPAs) Angela Panushkina and Perchui Milena Khurshudyan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPAs met with the Executive Director and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:05am, LPAs requested resident and staff roster. At 10:10am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Shower Log, etc., relevant to the investigation. At approximately 10:15am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:20am – 12:30pm, LPAs interviewed the Executive Director, two (2) MedTechs, two (2) staff, Maintenance Tech and seven (7) residents. Also, while interviewing a sample of seven (7) residents, LPAs randomly tested resident’s pendant and emergency call buttons in bathrooms.
Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
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 5
Control Number 31-AS-20240416105120
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: 04/17/2024
NARRATIVE
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Allegation: Staff does not respond to resident’s pendant call.

It was alleged that the facility staff do not respond to residents' pendant and emergency pull cords. To investigate this allegation, LPAs conducted a random inspection of two (2) pendants and three (3) emergency pull cords in the bathrooms. The facility’s expectation for response time is 10-15 minutes. However, during the inspection only one (1) pendant call was received by the facility and a caregiver responded to the call in seventeen (17) minutes. Moreover, at 2:36pm, LPAs along with the Executive Director tested residents' pendant and emergency cord in room #153 and waited until 2:56pm. No staff showed up to reset the call buttons. Based on LPA's observation and review of the information received, this allegation is Substantiated.

Allegation: Staff not maintaining resident’s hygiene.

It was alleged that on 03/31/24 R1 came back from the hospital/rehabilitation and was not given a shower since the facility had no shower chair. To investigate this allegation, LPAs conducted interviews with the Executive Director, two (2) MedTechs and one (1) out of two (2) staff members. Interview with the Executive Director and facility staff revealed that R1's family was requested to purchase/provide a shower chair, which was delivered on 04/15/24. Although the shower chair was already delivered/received, it was not assembled until 04/16/24. Moreover, LPAs conducted review of the facility shower log and observed that R1 was scheduled to have a shower on 04/15/24, but no shower was provided to the present day. Therefore, based on interviews and record reviews this allegation is Substantiated.

Deficiencies issued per Title 22.

Exit interview conducted appeal rights explained and copy of this report provided to the Executive Director.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20240416105120
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2024
Section Cited
CCR
87303(a)(2)
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Maintenance and Operation: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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Licensee/Administrator will test all residents pendants and emergency cords and provide an in-service training to all staff. Copy of training will be submitted to LPA.
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Based on LPAs inspection the licensee did not comply with the section cited above. Staff did not respond to 2 out of 3 resident’s pendant and 3 out of 3 emergency cord devices, which poses/posed a potential health and safety risk to persons in care.
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Type B
04/24/2024
Section Cited
CCR
87464(d)
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Basic Services: (d) if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs ... and providing the other basic services.
This requirement is not met as evidenced by:
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Licensee will provide an in-service training and submit proof of training to LPA
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Based on interviews and record review, the licensee did not comply with the section cited above by not arranging/scheduling a shower for R1 for over two (2) weeks, which poses/ posed a potential Health, Safety or Personal Rights risk to persons in care
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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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/16/2024 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20240416105120

FACILITY NAME:BROOKDALE CHATSWORTHFACILITY NUMBER:
191221435
ADMINISTRATOR:DANNY VERAFACILITY TYPE:
740
ADDRESS:20801 DEVONSHIRE BLVDTELEPHONE:
(818) 341-2552
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:268CENSUS: 129DATE:
04/17/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Danny Vera, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Resident sustained an unexplained fracture while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 10:00am, Licensing Program Analysts (LPAs) Angela Panushkina and Perchui Milena Khurshudyan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPAs met with the Executive Director and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:05am, LPAs requested resident and staff roster. At 10:10am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Shower Log, etc., relevant to the investigation. At approximately 10:15am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:20am – 12:30pm, LPAs interviewed the Executive Director, two (2) MedTechs, two (2) staff, Maintenance Tech and seven (7) residents. Also, while interviewing a sample of seven (7) residents, LPAs randomly tested resident’s pendant and emergency call buttons in bathrooms.
Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20240416105120
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: 04/17/2024
NARRATIVE
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It was alleged that the resident sustained unexplained fracture while in care. To investigate this allegation, LPAs conducted an interview with R1 and were informed that he/she lived at this facility since 2017 and required no help of any kind. LPAs were also informed that on 03/20/24, while walking towards the lobby, to pick up the mail, R1 did not buckle the footwear properly which led R1 to twist the ankle and lose balance. 9-1-1 was called and R1 was taken to the hospital and diagnosed with Right Femur and Right Humerus Fracture. Although the resident sustained unexplained fracture, interview with R1 revealed that he/she is happy with the care provided and did not blame the facility for the incident. Based on interviews and record reviews this allegation is deemed Unsubstantiated 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: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5