191221435-12-7-2022-31-AS-NGID-CMLVLM-20221230153209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191221435
Report Date: 12/07/2022
Date Signed: 12/07/2022 04:44:16 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
11/29/2022 and conducted by Evaluator Joscelyn Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20221129135427

FACILITY NAME:	BROOKDALE CHATSWORTH		FACILITY NUMBER:	191221435
ADMINISTRATOR:	HELEN LEE		FACILITY TYPE:	740
ADDRESS:	20801 DEVONSHIRE BLVD		TELEPHONE:	(818) 341-2552
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	268	CENSUS: 127	DATE:	12/07/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Helen Lee		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Facility staff is providing glucose testing

INVESTIGATION FINDINGS:

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On 12/07/22 Licensing Program Analyst (LPA) Joscelyn Martinez conducted an unannounced complaint investigation visit. Upon arrival LPA met with administrator Helen Lee and the purpose of the visit was explained.

Allegation: Facility staff is providing glucose testing

To investigate this allegation LPA conducted interviews with staff and residents. LPA also collected relevant documents pertaining to the investigation. LPA requested a census of all of the residents that are diabetic which were a total of six (6). LPA was able to interview five out of the six residents. Interviews with residents revealed that three (3) out of five (5) residents have their glucose tested by staff using blood. This is done by staff needing to prick resident's finger. Additionally one (1) out of five (5) residents stated that staff administer their insulin medication.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

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 3

Control Number 31-AS-20221129135427

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: 12/07/2022

NARRATIVE

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LPA interviewed five med-techs. Interviews revealed that four (4) out of five (5) med-techs have administer glucose testing to residents by pricking their fingers and using the blood to obtain a reading. Additionally, two staff stated they have administer insulin to residents when the resident is unable to do it themselves. Based on interviews this allegation is deemed Substantiated at this time.

Deficiency cited on 809-D. Exit interview conducted. Report signed and delivered. Appeal rights delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20221129135427

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: 12/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/08/2022 Section Cited CCR 87628(a)	1 2 3 4 5 6 7	87628(a) Diabetes The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through...	1 2 3 4 5 6 7	Staff are to immediately stop testing glucose by blood and administering insulin. Administrator is to provide training on restricted health conditions and will have staff sign stating they understand the training and regulation.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews from staff and residents it was revealed that staff are testing residents glucose by blood as well as administering insulin. Staff are not certified and skilled professionals which poses an immediate risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

LIC9099 (FAS) - (06/04)

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