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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191221435
Report Date: 07/01/2022
Date Signed: 07/01/2022 01:11:49 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
06/28/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210628140259
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: 122DATE:
07/01/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lilit MnatsaykanyanTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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9
Facility staff charged resident for services not needed
Facility did not provide a copy of the resident's records to the resident representative in a timely manner
Facility staff did not answer resident's emergency call signal in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegations above. LPA met with facility staff and explained the reason for this visit.

Facility staff charged resident for services not needed
It is alleged that resident #1 (R1) was charged for medication services even though their personal physician had cleared R1 to be able to handle their own medication. It is alleged that R1 was charged a total of an additional four thousand dollars over March, April, and May 2021. Initial complaint visit was conducted on 7/07/21. LPA had previously conducted an interview with R1 regarding this allegation on 6/25/22 and obtained copies of pertinent records related to the allegation. Information obtained from interviews reveal that R1 was charged for medication management even though R1 did not need medication management. Based on the information obtained this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
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 5
Control Number 31-AS-20210628140259
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: 07/01/2022
NARRATIVE
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Facility did not provide a copy of the resident's records to the resident representative in a timely manner
It is alleged that a representative for R1 and someone that is allowed to obtain copies of pertinent information related to R1's file was not provided copies of R1's records in a timely manner. LPA conducted interviews with R1's representative and facility staff regarding this allegation. LPA also obtained copies of emails regarding the request for R1's records between R1's representative and the administrator. Information obtained from interviews and documents obtained show that the facility failed to give copies of R1's records in a timely manner. Based on the information obtained this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D.

Facility staff did not answer resident's emergency call signal in a timely manner
It is alleged that facility staff did not answer R1's emergency call signal in a timely manner. LPA conducted interview with R1 and facility staff regarding this allegation on 6/25/22 and 7/7/21. Based on the interviews conducted this allegation was deemed Substantiated. This allegation was also investigated in another complaint investigation at this facility with regards to complaint control number 31-AS-20210621140710. This complaint allegation was alleged around the same time as this allegation. Due to this already being investigated and cited no further citation will be issued with regards to this allegation.

Exit interview conducted. Copy of report issued.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/28/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210628140259

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: 122DATE:
07/01/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lilit MnatsaykanyanTIME COMPLETED:
01:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not issue resident a refund
Facility staff did not ensure resident was able to attend a medical conference
Facility staff did not dispense medications as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegations above. LPA met with facility staff and explained the reason for this visit.

Facility staff did not issue resident a refund
It is alleged that resident #1 (R1) was not issued a refund after the facility charged R1 for services R1 did not need for the months of April, March, and May 2021. LPA previously conducted a visit on 7/7/21 where LPA interviewed the administrator at the time. LPA spoke with R1 regarding this allegation on 6/25/22. Information from interviews reveal that R1's account was credited back the money they were charged for. LPA was able to verify that with the current administrator at the facility. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20210628140259
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: 07/01/2022
NARRATIVE
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Facility staff did not ensure resident was able to attend a medical conference
It is alleged that facility staff did not let R1 participate on a medical conference on 3/23/21 with R1's physician regarding R1 being able to handle their own medication. LPA interviewed R1 regarding this on 6/25/22 and had previously spoke with the administrator at the time of the first visit on 7/7/21. Information obtained through interviews reveal that R1 was able to attend the medical conference by telephone but had issues hearing the call clearly due to a medical condition. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time.

Facility staff did not dispense medications as prescribed
It is alleged that R1 was not given their medication on time as prescribed and it was given at different times. LPA conducted an initial interview with facility staff on 7/7/21 regarding this allegation. LPA conducted an interview with R1 on 6/25/22 regarding this allegation. LPA obtained copies of the medication administration record for review. Based on information obtained from interviews and record review there is not enough information to state that R1 was not given their medication as prescribed.
Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20210628140259
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: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2022
Section Cited
CCR
87507(f)
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87507(f) Admission Agreements. (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by:
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Corrected before visit. Facility corrected the error and R1 was issued a credit for charges they had received.
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Based on interviews and record review facility charged R1 for services that were not needed which posed a potential health, safety, and personal rights risk to residents in care.
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Type B
07/01/2022
Section Cited
CCR
87506(c)(1)
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87506(c)(1) Resident Records. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement is not met as evidenced by:
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Corrected before visit. R1's records were made available.
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Based on interviews it was found that facility failed to make R1's records available to R1's designee in a timely manner even though written and verbal consent was given. This posed a potential health, safety, and personal rights risk to residents 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5