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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221435
Report Date: 11/26/2024
Date Signed: 11/27/2024 11:58:36 AM

Document Has Been Signed on 11/27/2024 11:58 AM - 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:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Dimple Kamdar, Operations Specialist/Administrator TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analysts (LPAs), Angela Panushkina and Huma Rahimi, conducted unannounced annual visit. LPAs met with the Operations Specialist/Administrator - Dimple Kamdar and Business Office Manager - Veronica Gomez and explained the reason for the visit.

Upon arrival, LPAs requested facility Staff and Resident Roster. LPAs were informed that the facility currently has one hundred and twenty eight (128) residents and four (4) caregivers and two (2) MedTechs.

At 9:30am, LPAs conducted a physical plant tour with the Business Director and the following was observed:

Common Areas: The facility maintains a comfortable temperature at 72°F. There are approximately one hundred and eighty (180) rooms at the facility. Moreover, LPAs were informed that the facility has three (3) libraries, two (2) activity rooms, a movie theater and a dining area. Facility has four (4) medication carts throughout the facility (Cart #1 by room #302, cart #2 by room #179, cart #3 by room #140 and cart #4 by room #224) and LPAs observed all carts locked and inaccessible to residents. Fire extinguishers were last serviced on 03/27/2024. Smoke detectors are tested annually by the Fire Department and LPAs obtained a copy of the report dated on 08/24/2024.



Bedrooms: LPAs observed three (3) half rail beds in rooms #421, #202 and #214 and one (1) full bed rail bed in room #228. Physician's order for half/full bed rails were not available upon request. In addition, at 12:49pm, LPAs passed by room #404 and observed a strong urine like smell. LPAs were informed that the facility does carpet deep cleaning every other day, however, the facility still can't get rid of the smell. Moreover, LPAs observed dirty carpets in the following rooms: #204, #256, #244 and #175 and in hallways. LPAs requested all room and hallway carpets to be cleaned. Furthermore, LPAs observed room #230 and #228 had an audio and video surveillance. LPAs requested all audio to be turned off immediately.

Continue on LIC809-C

Nichelle GillyardTELEPHONE: (818) 596-4341
Angela PanushkinaTELEPHONE: 747-230-3364
DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 11/26/2024
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Due to time constraints, LPAs were unable to complete the annual visit. LPAs will conduct a follow up visit to finish the report/deficiencies on another day.

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: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
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