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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191221435
Report Date: 11/22/2024
Date Signed: 11/22/2024 02:59:59 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
10/02/2024 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20241002095036
FACILITY NAME:BROOKDALE CHATSWORTHFACILITY NUMBER:
191221435
ADMINISTRATOR:DANNY VERAFACILITY TYPE:
740
ADDRESS:20801 DEVONSHIRE BLVDTELEPHONE:
(818) 341-2552
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:268CENSUS: 128DATE:
11/22/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Anchirriza Concepcion, Health and Wellness Director TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff does not respond to resident’s pendant call.
Staff not maintaining resident’s hygiene.
INVESTIGATION FINDINGS:
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At 09:00am, Licensing Program Analysts (LPAs), Angela Panushkina and conducted a subsequent visit to deliver final report. LPAs met with the Operations Specialist - Dimple Kamdar and Business Office Manager - Veronica Gomez and and Health and Wellness Director - Anchirriza Concepcion, and explained the reason for the visit.

Initial visit was conducted on 10/09/24 and during course of the investigation, LPA requested resident and staff roster. At 09:45am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Shower Log, Alarm History (pendant and emergency pull cords) for the months of September 2024 and Staff Training relevant to the investigation. At approximately 10:00am, LPA 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. Between 10:20am – 02:00pm, LPA conducted an interview with the Business Office Manager, four (4) staff, and eight (8) out of thirteen (13) residents. Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 31-AS-20241002095036
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: 11/22/2024
NARRATIVE
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 LPA randomly tested resident’s pendant and emergency pull cords in rooms and bathrooms.

Allegation: Staff does not respond to resident’s pendant call.
It was alleged that the facility staff do not respond to residents' pendant and emergency pull cords. To investigate this allegation, during the initial visit, LPA conducted a random inspection of three (3) pendants and five (5) emergency pull cords in resident's rooms and bathrooms. The facility’s expectation for response time is 10-15 minutes. During the inspection two (2) pendant calls were addressed within the facility time frame. However, the third pendant call was made at 11:07am and was not reset by the facility staff until LPA asked S2 to reset it at 11:33am (26 minutes later). Moreover, at 11:58am LPA tested bathroom emergency cord in room #319 and S3 came into the room at 12:06pm and reset the room pull cord instead. In addition, at 12:23pm LPA tested room and bathroom emergency cords in room #148 and S1 came into the room and reset the bathroom cord only. Furthermore, at 12:23pm LPA tested the room emergency cord in room #315 and waited until 12:38pm. No staff showed up to reset the emergency cord. Lastly, review of facility Alam History from 09/10/24 (12:56pm) to 09/30/24 (6:44pm) revealed that six hundred forty-five (645) pendant/pull cord calls were resolved between sixteen (16) minutes to one (1) hour and twenty-seven (27) minutes later. Based on LPA's observation, inspection and record review this allegation is Substantiated.

Allegation: Staff not maintaining resident’s hygiene.
It was alleged that on 09/09/24 R1 was transferred from the hospital to sub-acute rehabilitation for 2 weeks and when R1 came back to the facility from the hospital/rehabilitation on 09/24/24, no shower was provided to R1 until 10/05/24. To investigate this allegation, LPA conducted interviews with the Wellness Director and Business Office Manager. Interview with both parties revealed that R1 refused to have a shower. Facility has a document signed by the resident when they refuse showers. However, the facility could not provide LPA the proof that R1 did refuse shower for that week. Moreover, LPA conducted review of the facility shower log and observed that R1 was scheduled to have a shower on 10/05/24, but no shower was scheduled prior to that day. Therefore, based on interviews and record reviews this allegation is Substantiated.

Deficiencies issued per Title 22 on LIC9099-D


Exit interview conducted appeal rights explained and copy of this report provided to the Executive Director.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20241002095036
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: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/24/2024
Section Cited
CCR
87303(a)(2)
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Maintenance and Operation: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful... ...furnishings and equipment.
This requirement is not met as evidenced by:
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Licensee/Administrator will test all residents’ pendants and emergency cords and provide an in-service training to all staff. Copy of training will be submitted to LPA
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Based on LPAs inspection the licensee did not comply with the section cited above. Staff did not respond to 2 out of 3 resident’s pendant and 3 out of 3 emergency cord devices, which poses/posed a potential health and safety risk to persons in care.
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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.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20241002095036
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: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2024
Section Cited
CCR
87464(d)
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Basic Services: (d) if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs ... and providing the other basic services.
This requirement is not met as evidenced by:
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Licensee will provide an in-service training and submit proof of training to LPA
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Based on interviews and record review, the licensee did not comply with the section cited above by not arranging/scheduling a shower for R1 for over two (2) weeks, which poses/ posed a potential Health, Safety or Personal Rights risk to persons in care
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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.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

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
LIC9099 (FAS) - (06/04)
Page: 4 of 4