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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191221435
Report Date: 10/20/2021
Date Signed: 10/20/2021 12:20:41 PM



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
09/10/2021 and conducted by Evaluator Joscelyn Martinez
COMPLAINT CONTROL NUMBER: 31-AS-20210910150020
FACILITY NAME:BROOKDALE CHATSWORTHFACILITY NUMBER:
191221435
ADMINISTRATOR:DINA DAVISFACILITY TYPE:
740
ADDRESS:20801 DEVONSHIRE BLVDTELEPHONE:
(818) 341-2552
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:268CENSUS: 121DATE:
10/20/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator- Dina DavisTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident is being overcharged for services not rendered
INVESTIGATION FINDINGS:
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At 11:00 AM, Licensing Program Analysts (LPAs) Joscelyn Martinez and Melissa Ruiz arrived at the facility to conduct an unannounced subsequent complaint investigation visit. Upon entry, LPAs were greeted by a staff member and later met with administrator Dina Davis. The purpose of this visit was explained. LPAs conducted an initial ten-day complaint visit on 09/16/2021. During that visit LPAs conducted interviews with twelve (12) residents, six (6) staff members, and the administrator. LPAs also obtained relevant documentation that includes but not limited to, R1’s Physician Report, Assessment Summary, Progress Reports, and Account History Report.
Two (2) out of twelve (12) residents complained about being over charged for services that were not rendered. One (1) of those two (2) residents stated she was mistakenly charged for a smoking fee, but a credit was issued to her account right away.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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 2
Control Number 31-AS-20210910150020
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: 10/20/2021
NARRATIVE
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Out of six (6) staff members interviews, all of them stated they were aware that R1 has received additional services such as medication administration, dressing, grooming, and toileting needs at some point during her time at this facility.
Based on R1’s updated Physician Report, R1 needs assistance with Self-Care and Medication Management. Based on document review, the assessment summary revealed that these were the additional services that were rendered to R1.
Based on the information obtained, the allegation “Resident being overcharged for services not rendered” is unsubstantiated at this time. No deficiencies issued. Exit interviewed conducted and report was delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2