197606676-4-16-2022-31-AS-NGID-CGHPKW-20220720112349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606676
Report Date: 04/16/2022
Date Signed: 04/16/2022 03:30:37 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
04/15/2019 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20190415121636

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: 47	DATE:	04/16/2022
		UNANNOUNCED	TIME BEGAN:	08:48 AM
MET WITH:	Zuleyma Gomez - Health and Wellness Director		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff fails to meet resident's hygiene needs

Due to neglect, resident sustained infection requiring hospitalization

INVESTIGATION FINDINGS:

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

LPA conducted physical plant tour with the staff at 9:00 AM, requested copies of facility documents relevant to the investigation at 9:22 AM and reviewed records between 9:30 AM to 2:00 PM.

Regarding the allegation that facility staff fails to meet resident's hygiene needs, it was alleged that Resident #1 (R1) was not cleaned properly and left in soiled diaper for extended period of time. LPA's record review today at 9:15 AM revealed that R1 was capable self care including but not limited to toileting and dressing and needed assistance on bathing. R1's last physical check up was on 01/19/19.

(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: 04/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2022

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-20190415121636

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: 04/16/2022

NARRATIVE

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(continued from LIC 9099)

Further record review of R1's Personal Service Plan (PSP) dated 06/15/18 and 12/15/18 signed by R1's Power of Attorney (POA) also revealed that R1 did not need bathroom assistance. Additionally, then LPA Gillyard's record review on 01/15/2020 revealed that R1 refused assistance from care staff numerous times during R1's stay at the facility. Then LPA Gillyard's interview with one (1) staff on 04/24/19, LPA Mita Amin's interview with two (2) staff on 01/15/20 and LPA Tan's interview with three (3) staff on 04/07/22 between 11:00 AM to 1:00 PM confirmed that R1 refused to be assisted at times, be it dressing, changing diapers, showering and/or housekeeping. Further, all of six (6) staff interviewed also revealed that they consistently check on R1 every two (2) hours as directed and change R1's diapers regularly and as needed but unable to do so when R1 refused but always try to come back in thirty (30) minutes or less after R1's initial refusal but was still refused most of the time.

Regarding the allegation that due to neglect, resident sustained infection requiring hospitalization. It was alleged that R1 was hospitalized due to infection on 03/04/19 due to staff neglect. LPA's record review today at around 9:30 AM revealed that two (2) weeks prior to hospitalization of R1, there was no indication that R1 was being neglected by any staff but rather being closely monitored by all the staff and every changes or incident regarding R1 was reported to R1's family member such as behavioral episodes against another resident on 03/03/19 and 02/27/19 and Staff also reported about any changes in R1's medical condition such as having an eye condition to R1's family member on 02/27/19 at 2:06 PM.

Based on the information gathered during the course of the investigation, 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: 04/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2022

LIC9099 (FAS) - (06/04)

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