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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221435
Report Date: 12/17/2024
Date Signed: 12/17/2024 01:32:58 PM

Document Has Been Signed on 12/17/2024 01:32 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: 127DATE:
12/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Amanda Monroy, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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At 10:30am, Licensing Program Analyst (LPA), Angela Panushkina, Regional Manager (RM), Angela Wittaker, Licensing Program Manager (LPM), Nichelle Gillyard along with the Fire Inspector, Linsay Pellegrini conducted a Case Management visit. The team met with the Executive Director, Amanda Monroy, and explained the reason for the visit.
LPA requested resident and staff roster. The facility currently has approximately thirty seven (37) non-ambulatory residents residing on a second floor. During the 10/10/24 visit, LPA informed the facility that this is a Health and Safety issue and requested to provide a Written Plan within 48-hours. However, during today's visit, a second request was made for the facility to submit a written plan. The team was informed that the facility continues to conduct routine checks on non-ambulatory residents every two (2) to four (4) hours. Executive Director will submit the Written Plan to LPA within 24-hours. In addition, Executive Director was provided a copy of the occupancy certificate, issued by Building and Safety, which indicates "No Non-Ambulatory" residents on a second floor.
At approximately 11:00am, LPA, LPM, RM and the Fire Inspector conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Fire Inspector recommended a search protector to be used for all decoration cords. A chair in a hallway, by the room #120, blocked the clearance and the Fire Inspector requested the chair to be removed/relocated. At 11:30am, the team went up the stairwell to inspect the roof access. Executive Director informed the team that once the door opened, each employee receives a notification on their pagers for an immediate assistance. The Fire Inspector recommended an auditory alarm also to be placed on all "roof access" doors for an extra safety. It was observed that Maintenance storage door and housekeeping carts which stored chemicals were unlocked and upon request the Executive Director immediately locked and removed all chemicals. The team requested an additional training/meeting to be provided to all staff.

No deficiency issued during todays visit.
Exit interview conducted and copy of this report signed and delivered.
Nichelle GillyardTELEPHONE: (818) 596-4341
Angela PanushkinaTELEPHONE: 747-230-3364
DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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