191221435-12-24-2025-31-AS-NGID-DRZVAK-20260309161602

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191221435
Report Date: 12/23/2025
Date Signed: 12/24/2025 01:13:12 PM

Unsubstantiated

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
01/22/2025 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20250122143226

FACILITY NAME:	BROOKDALE CHATSWORTH		FACILITY NUMBER:	191221435
ADMINISTRATOR:	TIERNY DENISE WILBURN		FACILITY TYPE:	740
ADDRESS:	20801 DEVONSHIRE BLVD		TELEPHONE:	(818) 341-2552
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	0	CENSUS: 138	DATE:	12/23/2025
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Antonio Cortez, Business Office Manager		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff did not provide adequate supervision resulting in resident wandering away from facility.

INVESTIGATION FINDINGS:

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At 09:30am, Licensing Program Analyst (LPA), Angela Panushkina, conducted a subsequent visit to deliver final report. LPAs met with Antonio Cortez, Business Office Manager, and explained the reason for the visit.

During the initial visit, conducted on 01/23/25, LPA requested resident and staff roster. At 9:15am requested copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan, Staff Training, relevant to the investigation. At approximately 9:25am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 10:30am - 1:30pm, LPA conducted an interview with the Administrator, Health and Wellness Director, one (1) MedTech, four (4) staff and (4) out of seven (7) residents.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250122143226

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: 12/23/2025

NARRATIVE

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Allegation: Staff did not provide adequate supervision resulting in resident wandering away from facility.

To investigate this allegation, LPA conducted an interview with the Administrator and was informed that R1 had been living at this facility for three (3) years. Based on a Physician’s Report (dated on 06/26/24) R1 was able to leave the facility unassisted. Administrator also informed LPA that no major changes have been observed in R1’s mental condition. Facility entry door is always unlocked. Residents/staff may open the door from the inside, however, no one can get in from the outside before 8:00am or after 7:00pm. Interview with S1 revealed that, at approximately 7:30am, S1 conducted morning routine and visited R1’s room. S1 stated: “I didn’t see R1, so I assumed that R1 already went to the dining area for breakfast.” After discovering that R1 is not present at the dining area, S1 immediately paged all staff members for an assistance to search for R1. Interview with the Wellness Director confirmed the statement provided by S1 and LPA was informed that WD immediately contacted the Northridge Hospital to report and or obtain information. Hospital nursing station informed WD that around 7:30am, R1 was found by the facility and picked up by 911 Paramedics. As of 8:00am, R1 was admitted to the hospital and was receiving medical care for her injuries. LPA requested R1’s medical records on 01/24/25 and received it on 02/25/25. Review of R1’s medical records revealed that upon admission, R1 was heavily bruised all over his/her face, has a hematoma on his/her forehead and bruising around both yes and down the side of her neck. R1 was unable to recall what happened, stated that he/she may have gotten in a fight. Lastly, LPA conducted interviews with seven (7) residents and four (4) out of seven residents informed LPA that they may leave the facility unassisted, due to Assisted Living (Independent Living) at Brookdale. However, immediate assistance can also be provided by the staff upon residents’ request. All residents interviewed expressed no concerns regarding this allegation and informed LPA that staff is very well trained to provide extra attention, care and supervision to all residents. Based on interviews and record reviews R1 did not wander from the facility as R1 was independent and able to leave this facility as desired. Therefore, this allegation is deemed Unsubstantiated, at this time.

No deficiency cited during today's visit.
Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025

LIC9099 (FAS) - (06/04)

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