191221839-9-3-2021-28-AS-CYEE-C723EC-20210919181053

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191221839
Report Date: 09/03/2021
Date Signed: 09/03/2021 09:54:34 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/27/2021 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210827123656

FACILITY NAME:	BROADVIEW RESIDENTIAL CARE CENTER		FACILITY NUMBER:	191221839
ADMINISTRATOR:	BETSY K DAVIS		FACILITY TYPE:	740
ADDRESS:	535 WEST BROADWAY		TELEPHONE:	(818) 246-4951
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91204
CAPACITY:	180	CENSUS: 59	DATE:	09/03/2021
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Betsy Davis		TIME COMPLETED:	10:05 AM

ALLEGATION(S):

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9

Resident sustained unexplained injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong conducted a complaint investigation for the allegation listed above. LPA met with Betsy Davis, the Administrator and explained the purpose of the visit.

During today’s visit, LPA interviewed the Administrator, one staff and obtained a copy of the staff and resident roster. LPA also interviewed the Administrator from the Broadway Manor (skilled nursing home) at 605 W. Broadway Glendale 91204 and obtained the resident roster for Broadway Manor.

Based on interview and document reviewed, Resident #1 (R1) did not reside at this facility but at the Broadway Manor. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted. A copy of the report was provided to to the adminsitrator Betsy Davis

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

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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