197602414-11-4-2021-31-AS-NGID-C9STPT-20211217135453

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602414
Report Date: 11/04/2021
Date Signed: 11/04/2021 04:35:04 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
10/19/2020 and conducted by Evaluator Shira Stamps

COMPLAINT CONTROL NUMBER: 31-AS-20201019161446

FACILITY NAME:	BROOKDALE NORTH TARZANA		FACILITY NUMBER:	197602414
ADMINISTRATOR:	DAVIS, DINA		FACILITY TYPE:	740
ADDRESS:	5711 RESEDA BLVD		TELEPHONE:	(818) 996-2022
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	135	CENSUS: 56	DATE:	11/04/2021
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Dana Anderson, Administrator		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff stole from Resident.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Shira Stamps and Angela Panushkina met with the Administrator Dana Anderson at 2:20pm for a complaint investigation.

At 2:30pm LPAs requested LIC500 and room roster. LPA requested and reviewed residents file at 3:20pm. File review consists but is not limited to, review of the physician report, resident care plans, relevant logs,etc
.
LPA conducted a tour and interviewed a sample of 10 residents from 3:30pm to 3:55pm.
During tour LPA randomly tested a one resident’s pendant and staff responded in a timely manner.

LPA conducted sample interviews with three(3) out of five(5) staff indicated that some residents previously misplaced their belongings/items, but in 9 out of 10 times the items were found.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

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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Control Number 31-AS-20201019161446

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 NORTH TARZANA	FACILITY NUMBER: 197602414
	VISIT DATE: 11/04/2021

NARRATIVE

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Interviews of nine(9) out of ten (10) residents indicated they have not had any items go missing. Therefore, after review of the information received the allegation, staff steals from residents is unsubstantiated at this time.

No deficiency issued.

Exit interview conducted.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC9099 (FAS) - (06/04)

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