197602414-11-4-2021-31-AS-NGID-C9SNUU-20211217094654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602414
Report Date: 11/04/2021
Date Signed: 11/04/2021 04:36:16 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
10/28/2020 and conducted by Evaluator Shira Stamps

COMPLAINT CONTROL NUMBER: 31-AS-20201028120616

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:	11:30 AM
MET WITH:	Dana Anderson, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to meet Residents needs.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Shira Stamps and Angela Panushkina met with the Administrator Dana Anderson at 11:30am for a complaint investigation.

At 11:45am LPAs requested LIC500 and resident roster. LPAs requested resident files at 11:50am and review of files was conducted at 12:20pm. File review consists but is not limited to, review of the physician report, resident care plans, relevant logs,etc.
LPAs conducted a tour and interviewed a sample of 10 residents from 1:15pm to 2:15pm.
During tour LPAs randomly tested a one resident’s pendant and staff responded in a timely manner.

LPA conducted sample interviews three(3) out of five(5) staff members. Interviews with three (3)staff members indicated that there is sufficient staffing to meet the needs of the resident’s timely due to their communication with each other. Three out of five staff indicate that there is a no staffing issue when

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)

Page: 1 of 2

Control Number 31-AS-20201028120616

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

someone calls in sick. The Director or Health and Wellness Director will step in the position of caregiver to assist and help staff. Interviews also indicated that the Med Tech will step in to assist caregivers as needed. Moreover, Interviews with 9 out of 10 residents, who are able to communicate, indicated that staff are meeting their needs within a timely manner and are happy with services. Therefore, after review of the information received the allegation, Staff failed to meet residents needs, is unsubstantiated at this time.

No deficiency issued.

Exit interview conducted.Report delivered.

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)

Page: 2 of 2