<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602414
Report Date: 04/13/2021
Date Signed: 04/13/2021 05:07:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 TARZANAFACILITY NUMBER:
197602414
ADMINISTRATOR:DAVIS, DINAFACILITY TYPE:
740
ADDRESS:5711 RESEDA BLVDTELEPHONE:
(818) 996-2022
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:135CENSUS: 69DATE:
04/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Anchirriza ConcebcionTIME COMPLETED:
03:00 PM
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
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced case management visit due to an incident report that was submitted by the facility. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19) and to implement mitigation measures, today’s case management visit was conducted telephonically with staff Anchirriza Concebcion.

Facility self reported an incident regarding resident #1 (R1) stating they were hit by a staff member back in January or February. Facility was contacted by R1's family regarding the situation. Facility has conducted interviews with R1, R1's family, and R1's physician. Facility also contacted law enforcement regarding the situation. Due to the need for more information LPA will follow up on the facility regarding this situation at a later date. Exit Interview conducted. Copy of report emailed for signature.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1