197602414-8-13-2021-31-AS-CHAS-C82V5G-20211022160755

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602414
Report Date: 08/13/2021
Date Signed: 08/13/2021 02:30:50 PM

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
05/25/2021 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20210525142927

FACILITY NAME:	BROOKDALE NORTH TARZANA		FACILITY NUMBER:	197602414
ADMINISTRATOR:	DANA ANDERSON		FACILITY TYPE:	740
ADDRESS:	5711 RESEDA BLVD		TELEPHONE:	(818) 996-2022
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	135	CENSUS: 56	DATE:	08/13/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Dana Anderson		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained multiple injuries while in care.

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 investigate the allegation above. LPA met with the administrator and explained the reason for this visit.
It is alleged that resident #1 (R1) was admitted to the hospital on 5/20/21 with multiple stage one pressure injuries. LPA previously conducted an initial visit on 5/26/21 where LPA reviewed R1's facility file, obtained copies of pertinent information from R1's facility file which included home health records and R1's service plan.
Information obtained during that first visit revealed that R1 was moving out of this facility on 5/20/21 to BROOKDALE GARDENS OF TARZANA, 197606676 due to that facility having a roll in shower for mobility reasons. R1 was happy with the care they were receiving at this facility. At approximately 9:00 am LPA conducted a phone interview with R1. LPA also finished review of the documents obtained from previous visit. Information obtained revealed that R1 was receiving home health services for their wounds and their wounds were all stage 1. Interviews with R1 and facility staff reveal that R1 was receiving good care and R1's wounds were being handled by Kaiser Home health. Based on the information obtained through interviews and review of documents this allegation is deemed Unsubstantiated at this time. Exit interview conducted.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

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 2