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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221435
Report Date: 11/22/2024
Date Signed: 11/22/2024 03:10:49 PM

Document Has Been Signed on 11/22/2024 03:10 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/
DIRECTOR:		TIERNY DENISE WILBURNFACILITY TYPE:
740
ADDRESS:20801 DEVONSHIRE BLVDTELEPHONE:
(818) 341-2552
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 268TOTAL ENROLLED CHILDREN: 0CENSUS: 128DATE:
11/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Anchirriza Concepcion, Health and Welness DirectorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Angela Panushkina, conducted unannounced visit to this facility in conjunction with a complaint control # 31-AS-20240628153636. LPA met with the Operations Specialist - Dimple Kamdar, Business Office Manager - Veronica Gomez and Health and Wellness Director - Anchirriza Concepcion, and explained the reason for the visit.

On 06/28/24, the Regional Office (RO) received a complaint and on 07/03/24, LPA conducted an initial complaint visit. During the complaint investigation, LPA discovered that prior to R1’s fall incident that occurred on 06/25/24 (at around 2:30am), R1’s AC/Heater Unit was not properly working, and the initial work order was submitted on 06/23/24. Interview with the witness revealed that during the visit conducted on 06/25/24 they observed that R1’s AC/Heater Unit was still not fixed, and another work order was immediately submitted. Additionally, LPA conducted interview with three (3) staff members, who also confirmed that on a day of the incident they observed R1’s room temperature to be very high/hot and discovered that the AC/Heater Unit was broken. Lastly, LPA requested facility’s work order for R1’s AC Unit and observed that on 06/25/24 at 1:13pm an order was placed by R1’s family member.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC809-D.

Exit interview conducted, appeal rights and copy of report signed and delivered.
Nichelle GillyardTELEPHONE: (818) 596-4341
Angela PanushkinaTELEPHONE: 747-230-3364
DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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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Document Has Been Signed on 11/22/2024 03:10 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance... for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 11/28/2024
Plan of Correction
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Administrator will submit proof upon complition of the AC unit to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nichelle GillyardTELEPHONE: (818) 596-4341
Angela PanushkinaTELEPHONE: 747-230-3364

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

LIC809 (FAS) - (06/04)
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