197602414-3-17-2021-31-AS-CHAS-BZWTJV-20210409144657

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602414
Report Date: 03/17/2021
Date Signed: 03/17/2021 03:52:54 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
03/16/2021 and conducted by Evaluator Wendell Smith

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20210316091225

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: 69	DATE:	03/17/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Anchirriza Concebcion		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Facility failed to produce resident's records per request of responsible party

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith conducted a subsequent complaint visit regarding the allegation listed above. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19) and to implement mitigation measures, today’s complaint investigation was conducted telephonically with staff Anchirriza Concebcion.
It is alleged that the facility failed to produce resident's (R1) record per request of their responsible party. LPA conducted an initial complaint visit to this facility on 3/16/21 regarding this allegation. LPA conducted interviews with facility staff regarding this allegation. Information obtained through this interview revealed that
R1 passed away on 1/31/21. Facility received a record request from a legal office representing R1's wife and supposed responsible person for R1. LPA conducted an interview with the Law Office who requested copies of R1's file. The Law office stated that they served a records request by fax on 3/11/21 and by mail on 3/12/21 and have not received anything from the facility. LPA spoke with facility staff who stated that they received the request on 3/15/21 and after looking at the file of R1 they noticed the person the law office stated was R1's responsible person was not the person who they had documented as R1's responsible person

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: 03/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2021

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-20210316091225

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: 03/17/2021

NARRATIVE

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and had never been in contact with that such person while R1 was at the facility. The facility stated they were going over what was requested with their legal department and would contact the law office who made the request. LPA requested and reviewed R1's admission agreement and identification and emergency information. Based on the information obtained through interviews and documents reviewed this allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2021

LIC9099 (FAS) - (06/04)

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