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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221435
Report Date: 10/10/2024
Date Signed: 10/10/2024 01:46:06 PM


Document Has Been Signed on 10/10/2024 01:46 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:TIERNY DENISE WILBURNFACILITY TYPE:
740
ADDRESS:20801 DEVONSHIRE BLVDTELEPHONE:
(818) 341-2552
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:268CENSUS: 135DATE:
10/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Dimple Kamdar, Operations SpecialistTIME COMPLETED:
02:15 PM
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A case management visit was conducted by Licensing Program Analyst (LPA) Angela Panushkina today based on a facility’s Non-Ambulatory status (for the 2nd floor) approved in error by the Fire Department in 1995 and 2011. LPA met with the Operations Specialist - Dimple Kamdar, District Director of Clinical Services - Leslie Tripp, Business Office Manager - Veronica Gomez, Wellness Director (LVN) - Anchirriza Concepcion and explained the reason for the visit.

The facility is currently cleared for 258 Non-Ambulatory residents on a 1st and 2nd floors with capacity of 268. Cleared for 10 Bedridden in rooms #107, 111, 119, 121,123,127, 161, 163, 165, 167. It was determined that there as a "Clerical error" made, twenty (20) years ago. Due to the Fire Clearance Safety Regional Office (RO) is requesting for an additional monitoring on 2nd floor. LPA informed the facility team, as this is a Health and Safety issue, to provide a following Written Plan within 48-hours:

1. A list of people that need to be relocated (non-ambulatory and or bedridden on a 2nd floor). LPA was informed that no bedridden residents currently reside on the 2nd floor. As for Non-ambulatory residents, the facility will submit Names and Room #'s of each resident by 5:00pm on 10/10/24.

2. Anticipated move for those residents will be as follows: LPA was informed that the families/residents must be informed and upon approval the family/resident will coordinate and organize the transfer with the help of community. An addendum must be in place and attached to a current Admission Agreement, due to room changes and pricing.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/10/2024
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3. When the facility anticipates completing this request by? LPA was informed that the Corporate Office will be contacted and more detailed information will be provided promptly.

LPA also informed the Operations Specialist, District Director of Clinical Services, Business Office Manager, and Wellness Director (LVN) that more frequent supervision on a 2nd floor, during this time, is required. All parties have agreed to include additional supervision on a 2nd floor, and in a mean time will have a consultation with their Legal Team.

No deficiencies issued during this visit.



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: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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