191221435-5-12-2022-31-AS-MVAO-CESSSG-20220526140756

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191221435
Report Date: 05/12/2022
Date Signed: 05/12/2022 09:51:26 AM

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
04/01/2021 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20210401150014

FACILITY NAME:	BROOKDALE CHATSWORTH		FACILITY NUMBER:	191221435
ADMINISTRATOR:	CHAPARYAN, LILIT		FACILITY TYPE:	740
ADDRESS:	20801 DEVONSHIRE BLVD		TELEPHONE:	(818) 341-2552
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	268	CENSUS: 117	DATE:	05/12/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Lilit Mnatsakanyan		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care.
Resident has fallen multiple times while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to conclude the investigation regarding the above allegations. During the course of the investigation, interviews and record review were made.

Resident sustained multiple pressure injuries while in care:
In regards to the allegation, according to facility Staff (S1), Resident 1 (R1) had wounds during her stay at the facility. Hospice Nurse came to the facility twice per week to treat R1’s wounds. R1’s wounds were not greater than stage 2. At one point, wounds did appear to heal, and wound care was discontinued. S1 confirmed her employment at the facility during the time of R1’s stay. A review of R1’s hospice records reveal that R1 had a blister to the lower leg, which healed. R1 also had a stage 2 wound to the buttock and a tissue/blistor injury to the left heel which also healed. Further review of R1’s hospice record and physician’s report do not indicate that R1 had a pressure injury

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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-20210401150014

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: 05/12/2022

NARRATIVE

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greater than a stage 2 while residing at the facility. Based on the information obtained through interviews and record review, there wasn’t enough evidence to prove that R1 sustained multiple pressure injuries while in care. Therefore, the investigation is deemed Unsubstantiated at this time.

Resident has fallen multiple times while in care:
In regards to the allegation, it’s reported that R1 has had repeated falls at the facility while in care. Although R1 requires the use of a wheelchair, mobility aid and escort service, a review of R1’s physician’s report, personal service plan and assessment summary does not indicate that R1 has a history of falling. Furthermore, interview with staff also does not corroborate resident falling multiple times while in care. Based on the information obtained, there wasn’t enough evidence to prove R1 had fallen multiple times while in care. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC9099 (FAS) - (06/04)

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