197606676-5-17-2022-31-AS-NGID-CGHNDB-20220720102159

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606676
Report Date: 05/17/2022
Date Signed: 05/17/2022 02:35:40 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:	05/17/2022
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Gina Grundeis - Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility failed to properly prepare food in result of E. Coli

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit to this facility to further investigate the above allegations. LPA met with Executive Director Gina Grundeis and explained the reason for the visit.

LPA conducted physical plant tour at around 9:30 AM, requested copy of facility documents relevant to the investigation at 10:00 AM and interviewed staff between 11:00 to 1:00 PM.

Regarding the allegation that the facility failed to properly prepare food in result of E. Coli, it was alleged that Resident #1 (R1) acquired E. Coli from the food served at the facility. LPA's record review today at around 10:15 AM revealed that the facility had no case of E. Coli since August of 2019 up to the present time. Further review also revealed that all the key kitchen staff were trained in food safety/handling. LPA's observation during physical plant tour and during lunch preparation also revealed that the kitchen is well organized and clean and food preparation was strictly supervised by the director. (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: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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: 05/17/2022

NARRATIVE

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(continued from LIC 9099)

LPA's interview with the Dining Services Director also revealed that he did not receive any report of any outbreak of E. Coli at the facility and should there be any from the food they served, it would have not been only on one person because they prepare the same food for everyone.

Based on the information gathered during the course of the investigation, there is insufficient information to support the allegation 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: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC9099 (FAS) - (06/04)

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