191221435-6-25-2022-31-AS-NMAN-CFT28A-20220627171002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191221435
Report Date: 06/25/2022
Date Signed: 06/25/2022 03:11:58 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
11/24/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20201124123601

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: 120	DATE:	06/25/2022
		UNANNOUNCED	TIME BEGAN:	08:46 AM
MET WITH:	Chariz Concepcion - Health and Wellness Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff failed to properly transfer resident out of the facility

Facility staff transferred resident to another facility without consent.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit at this facility to further investigate the above allegations. LPA met with Health and Wellness director Chariz Concepcion and informed the purpose of the visit.

LPA conducted physical plant tour at 10:02 AM. Requested copy of facility documents relevant to the investigation at 10:25 AM and interviewed staff and residents between 10:35 AM to 12:45 PM.

Regarding the allegation that facility staff transferred resident to another facility without consent, it was alleged that Resident #1 (R1) was moved to an Skilled Nursing Facility (SNF) without explanation. LPA's interview with R1 today at 11:30 AM, revealed that R1 was informed that R1 was positive for Covid 19 and had to be transferred to a SNF for isolation and medical care. LPA's record review today at 1:00 PM revealed that R1 was tested on 11/11/20 via PCR test and result came out on the morning of 11/13/20 and R1, R1's health care providers and Government agencies were informed. R1 was transferred at 5:45 PM on 11/13/20 to a SNF.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022

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-20201124123601

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: 06/25/2022

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that facility staff failed to properly transfer resident out of the facility, it was alleged that the SNF was unaware of R1's medical history or needs. LPA's record review today at 1:00 PM revealed that SNF was informed and aware of R1's medical history and needs as it had the physician orders of R1's medical needs on the day R1 was admitted at the SNF. LPA's interview with staff at 12:30 PM today, also revealed that for any Covid 19 related transfer, the facility call the SNF before the transfer for availability and discussion of the resident's condition if the SNF could accommodate the resident and send all the information pertaining to resident prior to resident's transfer.

Based on the information gathered during this and prior visit, there is insufficient information to support the allegations and therefore deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2022

LIC9099 (FAS) - (06/04)

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