191221435-12-3-2024-31-AS-APAA-DBLSG7-20241203125129

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191221435
Report Date: 12/03/2024
Date Signed: 12/03/2024 12:55:50 PM

Document Has Been Signed on 12/03/2024 12:55 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 CHATSWORTH		FACILITY NUMBER:	191221435
ADMINISTRATOR/ DIRECTOR:	TIERNY DENISE WILBURN		FACILITY TYPE:	740
ADDRESS:	20801 DEVONSHIRE BLVD		TELEPHONE:	(818) 341-2552
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY: 268	TOTAL ENROLLED CHILDREN: 0	CENSUS: 127	DATE:	12/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Amanda Monroy, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

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	Licensing Program Analyst (LPA), Angela Panushkina, conducted a subsequent Annual Visit to complete the report. LPA met with the Executive Director, Amanda Monroy, and explained the reason for the visit. During the physical plant tour, conducted on 11/26/24, LPAs observed the following: Upon entry into the room #207, LPAs observed the Resident #10 (R10) in a hospital bed which was placed against the wall and the bed was blocking the passageway. Bathrooms: At 11:53am LPAs observed six (6) loose pills placed on a top of the vitamin bottle in room #159. During the interview with the resident, LPAs were informed that the pills were placed on a bottle as a reminder to take them later. LPA requested all six (6) pills to be properly discarded. LPAs also observed filthy/dirty bathrooms in room #207, #159, #175 and #401. Appropriate grab bar and non-skid mat were also observed. The hot water temperature measured between 108.6-133.4°F. Lastly, LPAs observed walls in various rooms, bathrooms and hallways to be poorly scraped and the paint around the door jamb is peeling away, door knobs are loose/damaged and trash cans were missing the fitted lids. Outside areas: While walking towards the West Wing area, LPAs observed that an exit, double doors were open and a ceramic, chipped roof tiles were placed under the door to prevent them from closing. LPAs also observed seventeen (17) extra ceramic roof tiles placed on the grass, of which one (1) tile was broken. Moreover, the metal gutter on a second floor, by the room #287 was twisted/loose/falling apart. In addition, at 12:08pm, LPAs observed piece of molded carpet outside, under the balcony (room #182). Continue on LIC809-C

Nichelle Gillyard	TELEPHONE: (818) 596-4341
Angela Panushkina	TELEPHONE: 747-230-3364
	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

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 10

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: 12/03/2024

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

At 12:21pm, on a 2^nd floor of the West Wing side, LPAs observed a missing doorknob/lock. LPAs were informed that the room is used as a storage for a maintenance crew. LPAs opened the door and observed a molded wall, ceiling and fifteen (15), five (5) gallon paints on the floor accessible to residents in care. Furthermore, at 12:29pm, upon entry into the room #401, LPAs observed an “Oxygen in Use” sign missing (resident uses an oxygen tank/concentrator). In addition, LPAs observed two (2) area rugs in room #401 are wrinkled which can cause a tripping hazard. Lastly, various areas (by rooms #301, #418, #420 and #421) in hallways, were observed to have a leak on a ceiling and two (2) fire doors (by rooms #241 and #408) were broken/damaged. LPAs discussed the importance of maintaining the care and supervision to meet the needs of residents.

Kitchen: At 1:05pm, LPAs toured the kitchen and observed sufficient supplies of staple non-perishable for 1 week and perishable for 2 days. All knives and sharps in the kitchen were kept locked and inaccessible to residents in care. There are three (3), fully charged fire extinguishers by the kitchen. All trash cans had fitted lids to protect from cross contamination.

Laundry: There are four (4) laundry rooms throughout the facility. LPAs observed all detergents locked and inaccessible to residents in care.

Resident Files: Between 1:30pm to 4:30pm, LPAs conducted eighteen (18) resident and five (5) staff records review. The following was observed. Fifteen (15) out of eighteen (18) resident files were incomplete. Files were missing signed list of personal property (LIC621) for R3 and R9, Physician’s Report (LIC602) missing R6’s, R8’s and R10’s signatures/dates, ID/Emergency Information (LIC601) missing the date next to R9’s signature, Resident Preplacement (LIC603) missing signatures/dates and or 2^nd page for R1, R2 and R8 and Release of Medical Information (LIC605A) are missing or have not been signed for R5, R7 and R10. Please see LIC858 included with this report.

Staff Files: The following was observed. LPAs observed five (5) out of five (5) employee files were missing personnel records (LIC501). Documented medications and general training observed to be completed. Please see LIC859 included with this report.

Deficiencies and civil penalty issued on LIC809-Ds.

Exit interview conducted, appeal rights explained and copy of report signed and delivered

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 2 of 10

Document Has Been Signed on 12/03/2024 12:55 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs inspection and observation, during 11/26/24 visit, the licensee did not comply with the section cited above. At 12:29pm, LPA measured a hot water termperature in room #401 to be 133.4°F and at 12:50pm, the water temperature in room #421 was measured at 129.7°F. This poses an immediate health, safety risk to persons in care.
	POC Due Date: 12/05/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator agreed to adjust a hot water temperature. Licensee/Administrator will measure a hot water temperature twice a day (8am and 8pm) for seven (7) days and submit the log to LPA on 12/10/24

Section Cited

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation and interview, during 11/26/24 visit, the licensee did not comply with the section cited above. The maintenance storage, located on a West Wing side, had no doorknob/lock. LPAs observed fifteen (15) / five (5) gallons of paint on the floor accessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator will place a lock on storage door and submit proof of picture to LPA by POC date.

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 Gillyard	TELEPHONE: (818) 596-4341
Angela Panushkina	TELEPHONE: 747-230-3364
	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 3 of 10

Document Has Been Signed on 12/03/2024 12:55 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation and interview, the licensee did not comply with the section cited above to ensure residents' medications in room #159 are stored in its originally received container. LPAs observed six (6) pills placed on a top of the vitamin bottle in a bathroom. This, poses an immediate health, safety risk to persons in care.
	POC Due Date: 12/05/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator agreed to check all resident rooms (for open/damaged/loose medications). A licensed vendor must be hired to provide a medication training to all staff. Licensee must submit the name, agency, contact information, license number and the date scheduled to LPA by POC date. Copies of trainig will be submitted to LPA upon complition.

Section Cited

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation and record review, the licensee did not comply with the section cited above by failing to obtain a written Doctor's order for three (3) half bed rails in rooms #421, #202 and #214, which poses an immediate health, safety to persons in care.
	POC Due Date: 12/05/2024
	Plan of Correction
1 2 3 4	License/Administrator agreed to immediately remove all rails and obtain a written Dr. orders. Copies of orders must be submitted to LPA by POC date.

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 Gillyard	TELEPHONE: (818) 596-4341
Angela Panushkina	TELEPHONE: 747-230-3364
	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 4 of 10

Document Has Been Signed on 12/03/2024 12:55 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation and record review, during 11/26/24 visit, the licensee did not comply with the section cited above by not requesting an exception for a non hospice resident (in room #228) to have a full bed rail. Moreover, no written Doctors' order was observed on file, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/05/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator will remove the full bed rail and obtain a written Doctor's order for a 1/2 bed rail. Copy of Dr's order will be submitted to LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Gillyard	TELEPHONE: (818) 596-4341
Angela Panushkina	TELEPHONE: 747-230-3364
	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 5 of 10

Document Has Been Signed on 12/03/2024 12:55 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, on 11/26/24 visit, the licensee did not comply with the section cited above by having a dirty carpet in the following rooms: #204, #256, #244 and #175 and in hallways, including chipped walls/doors, molded ceilings and missing paint on the walls/doors (throughout the facility). Additionally, doorknobs in residents rooms and bathrooms were missing/broken, which poses/posed a potential health and safety risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator agreed to have faclitity carpet cleaned, replace all broken/damaged doorknobs and paint chipped/molded walls/doors/ceilings. Pictures will be submitted to LPA by POC date.

Section Cited

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, during 11/26/24 visit, the licensee did not comply with the section cited above by having a strong urine like smell/odor in room/bathroom (room #404), which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator will replace the carpet with vinyl or peel and stick flooring. Picture proof will be submitted to LPA by POC date.

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 Gillyard	TELEPHONE: (818) 596-4341
Angela Panushkina	TELEPHONE: 747-230-3364
	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 6 of 10

Document Has Been Signed on 12/03/2024 12:55 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs inspection and observation, during 11/26/24 visit, the licensee did not comply with the section cited above. Resident records were incomplete and or missing documents, which poses/posed a potential health and safety risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Licensee agreed to review and complete all facility residents' files. Written roster with resident name and date of file complition will be submitted to LPA by POC date.

Section Cited

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, during 11/26/24 visit, the licensee did not comply with the section cited above by not having a "No Smoking-Oxygen in Use sign" at the door (room #401), which poses/posed a potential health and safety risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator will conduct in-service training with all staff regarding this section and place necessarry signs by the entry, at each unit which currently has an oxygen. Copy of trainilng will be submitted to LPA by POC date.

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 Gillyard	TELEPHONE: (818) 596-4341
Angela Panushkina	TELEPHONE: 747-230-3364
	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 7 of 10

Document Has Been Signed on 12/03/2024 12:55 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personal Accommodations and Services: d) The following space and safety provisions shall apply to all facilities: 6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, during visit on 11/26/24, the licensee did not comply with the section cited above to ensure the exit door/passageway in room #207 was free of obstruction, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/05/2024
	Plan of Correction
1 2 3 4	Licensee/administrator will submit a written statement notifying the department what steps will be taken to clear this deficiency and to ensure such deficiency will not reoccur.

Section Cited

Fire Clearance. a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, during 11/26/24 visit, the licensee did not comply with the section cited above to ensure to maintain the conditions of the approved fire clearance. The 2 fire doors were broken/damaged/malfunctioning, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 12/05/2024
	Plan of Correction
1 2 3 4	The Administrator will contact a licensed professional to replace/fix the fire doors. Copy of invoice will be submitted to LPA by POC date.

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 Gillyard	TELEPHONE: (818) 596-4341
Angela Panushkina	TELEPHONE: 747-230-3364
	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 8 of 10

Document Has Been Signed on 12/03/2024 12:55 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions: (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, during 11/26/24 visit, the licensee did not comply with the section cited above by having seventeen (17) extra ceramic roof tiles placed on the grass, of which one (1) tile was broken/chipped. Moreover, the metal gutter on a second floor, by the room #287 was twisted/loose/falling apart. In addition, a piece of molded carpet was left outside, under the balcony (room #182). This poses a potential health, safety risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator will remove/store all items and provide in-service training to all staff. Copy of training will be submitted to LPA by POC date.

Section Cited

(f) Solid waste shall be stored and disposed of as follows: (1) Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease or of odors, create a nuisance, provide a breeding place or food source for insects or rodents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, during 11/26/24 visit, the licensee did not comply with the section cited above by not providing residents with a fitted lid trash cans (for the bathrooms/bedrooms), which poses/posed a potential health and safety risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator will replace all resident and visitor bathrooms with trash cans that have lids. Copy of receipts, pictures will be submitted to LPA by POC date.

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 Gillyard	TELEPHONE: (818) 596-4341
Angela Panushkina	TELEPHONE: 747-230-3364
	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 9 of 10

Document Has Been Signed on 12/03/2024 12:55 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: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personal Rights of Residents in All Facilities: a) Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) to have a reasonable level of personal privacy in accommodations, medical treatment, personal care and ... of resident and family groups. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, during 11/26/24 visit, the licensee did not comply with the section cited above by allowing audio recording in rooms #228 and #230, which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator will remove all facility resident’s audio and submit a written statement notifying the department what steps will be taken to clear this deficiency and to ensure such deficiency will not reoccur.

Section Cited

Personnel Records: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs record review, during 11/26/24 and today's visit, the licensee did not comply with the section cited above. Five (5) staff files were incomplete, missing forms, which poses/posed a potential health and safety risk to persons in care.
	POC Due Date: 12/10/2024
	Plan of Correction
1 2 3 4	Licensee agreed to update and complete missing forms for all staff members and include copies of all intial trainig certificates in a file. Written statement of all staff names with completed date of file updated files will be submitted to LPA by POC date.

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 Gillyard	TELEPHONE: (818) 596-4341
Angela Panushkina	TELEPHONE: 747-230-3364
	DATE: 12/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024

LIC809 (FAS) - (06/04)

Page: 10 of 10