197606676-5-21-2022-31-AS-NGID-CGHNDA-20220720102159

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606676
Report Date: 05/21/2022
Date Signed: 05/21/2022 03:29:21 PM

Unsubstantiated

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
08/12/2019 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20190812172003

FACILITY NAME:	BROOKDALE SOUTH TARZANA		FACILITY NUMBER:	197606676
ADMINISTRATOR:	GOLDBERG,ROBERT		FACILITY TYPE:	740
ADDRESS:	18700 BURBANK BLVD		TELEPHONE:	(818) 342-0003
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	90	CENSUS: 46	DATE:	05/21/2022
		UNANNOUNCED	TIME BEGAN:	08:28 AM
MET WITH:	Michelle Egan - Staff		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff failed to obtain medical treatment for resident
Staff use resident's personal hygiene products on other residents
Residents needs not being met
Staff are not following universal precautions

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPA met with staff Michelle Egan and explained the reason for the visit.

LPA conducted physical plant tour at 9:00 AM, requested copy of facility documents relevant to the investigation at 9:38 AM and interviewed residents and staff from 10:00 AM to 1:30 PM. Regarding the allegation that Staff failed to obtain medical treatment for resident, it was alleged that Resident #1 (R1) was ill for two (2) weeks and was not taken to the doctor. LPA's record review on 05/17/22 at 10:15 AM and today at 11:00 AM revealed that R1 was consistently checked upon by medication technicians whenever R1 was given medication. LPA's interview with medication technicians on 05/17/22 between 11:00 AM to 1:00 PM and today at 11:43 AM confirmed that all of the medication technician checked regularly on R1 and all other residents that may require attention and call for medical attention as soon as they deemed necessary. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2022

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-20190812172003

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 SOUTH TARZANA	FACILITY NUMBER: 197606676
	VISIT DATE: 05/21/2022

NARRATIVE

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Further record review also revealed that R1 was seen and/or had communication with R1's Primary Care Physician (PCP) and/or PCP's associate on 08/06/19, 08/12/19, 08/26/19 and 08/28/19 regarding R1's medical condition in August of 2019 alone.

Regarding the allegation that Staff use resident's personal hygiene products on other residents, it was alleged that Staff are forced to reuse gloves or change R1 with no gloves at all. Then LPA Gillyard's interview with four (4) care staff on 08/16/19 revealed that all of them did not re use any gloves or any other personal hygiene products on any other residents nor they witnessed any staff re using gloves or not wearing them when changing and/or attending to R1 or any resident. Further interview revealed all of the staff interviewed did not experience shortage of gloves or any other personal protective equipment (PPE) at the facility and did not use any resident's PPE supply to other resident. Then LPA Gillyard also conducted random review of medication cart on 08/16/19 and found that the medication cart had sufficient supplies of gloves.

Regarding the allegation that Residents needs are not being met, it was alleged that R1 was not receiving the proper care that R1 needs. LPA's record review on 05/17/22 at 10:15 AM and today at 11:00 AM revealed that R1 was on Home Health care since 02/04/19 until the time R1 left the facility on 10/18/19. LPA's interview with five (5) residents or more than 10% of current census, today between 10:00 AM to 12:30 PM revealed five (5) out of five (5) residents stated that all their care needs were being met by the staff.

Regarding the allegation that Staff are not following universal precautions, it was alleged that the facility does not provide staff with mask, gloves or gown to be protected when attending to R1 who was diagnosed with a communicable disease. LPA's record review on 05/17/22 at 10:15 AM and today at 11:00 AM revealed that R1 was diagnosed with a suspected communicable disease on 08/04/19 and communicated at the facility by R1's PCP on 08/06/19. R1 was immediately put on isolation and staff were advised to take precaution and to wear PPE upon entering R1's room upon leaning of R1's medical condition. Then LPA Gillyard's interview with four (4) care staff on 08/16/19 also revealed that they did not experience shortage of gloves or any other personal protective equipment (PPE) at the facility. Further, there was no report of any person, staff or resident, who got infected by the suspected communicable disease that could have originated from R1.

Based on the information gathered during this and prior visits, there is insufficient information to support the allegations and therefore deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2022

LIC9099 (FAS) - (06/04)

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