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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602414
Report Date: 08/20/2021
Date Signed: 08/20/2021 03:31:55 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
08/19/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210819151828
FACILITY NAME:BROOKDALE NORTH TARZANAFACILITY NUMBER:
197602414
ADMINISTRATOR:DANA ANDERSONFACILITY TYPE:
740
ADDRESS:5711 RESEDA BLVDTELEPHONE:
(818) 996-2022
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:135CENSUS: 56DATE:
08/20/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Dana AndersonTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff failed to provide adequate food service
Staff failed to treat resident with dignity and respect
Staff failed to assist resident in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit. LPA met with the administrator and explained the reason for this visit.

Staff failed to provide adequate food service
It is alleged that the food served is not of good quality and there is small portions given. At approximately 10am, LPA conducted a tour of the kitchen area and looked at the food supply. LPA also interviewed various residents regarding food service. At 11:30am, LPA observed lunch being served to residents. Information obtained through observation and interviews reveal that the food served is of good quality and that residents are happy with the food portions and service they receive. Based on the information obtained this allegation is deemed Unsubstantiated at this time.
Staff failed to treat residents with dignity and respect.
It is alleged that facility staff who work at reception are rude and mean. At approximately 10:30 am LPA conducted interviews with random residents regarding this allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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 4
Control Number 31-AS-20210819151828
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: 08/20/2021
NARRATIVE
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Interviews with residents reveal that there is no issue with how staff at reception are treating residents. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time.

Staff failed to assist resident in a timely manner
It is alleged that caregivers fail to assist residents with taking out their trash when needed. At approximately 10 am LPA conducted interviews with random residents regarding this allegation. Interviews reveal that they receive assistance in a timely manner when they ask to do anything. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
08/19/2021 and conducted by Evaluator Wendell Smith
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20210819151828

FACILITY NAME:BROOKDALE NORTH TARZANAFACILITY NUMBER:
197602414
ADMINISTRATOR:DANA ANDERSONFACILITY TYPE:
740
ADDRESS:5711 RESEDA BLVDTELEPHONE:
(818) 996-2022
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:135CENSUS: 56DATE:
08/20/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Dana AndersonTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit. LPA met with the administrator and explained the reason for this visit.

Facility is in disrepair
It is alleged that there is an entry hall light out on the second floor. LPA spoke with the administrator who stated that the entry hall light was not working and it was brought to the attention of the staff by one of the residents. Administrator stated that after two days it has been fixed. LPA conducted a walk through of the second floor at approximately 12:30 pm and observed the light to be fixed at this time. Based on the information obtained this allegation is deemed Substantiated at this time. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20210819151828
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2021
Section Cited
CCR
87303(a)
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Maintenance and Operation-The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
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Corrected before visit. Entry hallway light has been fixed.
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Based on interviews conducted an entry hall light on the second floor was not working which posed a health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4