197606676-1-29-2024-31-AS-NMAN-D2TNFS-20240226092558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606676
Report Date: 01/29/2024
Date Signed: 01/29/2024 02:18:23 PM

Substantiated

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
07/03/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230703102331

FACILITY NAME:	BROOKDALE GARDENS OF TARZANA		FACILITY NUMBER:	197606676
ADMINISTRATOR:	HELEN LEE		FACILITY TYPE:	740
ADDRESS:	18700 BURBANK BLVD		TELEPHONE:	(818) 342-0003
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	90	CENSUS: 67	DATE:	01/29/2024
		UNANNOUNCED	TIME BEGAN:	11:24 AM
MET WITH:	Amanda Monroy		TIME COMPLETED:	02:22 PM

ALLEGATION(S):

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Personal Rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at 11:20 am to deliver findings. LPA Smith met with facility staff and disclosed the purpose of this visit. The administrator was present at the facility.

Personal Rights: Due to neglect in care and supervision resident sustained multiple fractures

The initial visit was conducted by Licensing Program Analyst (LPA) Tihesha Smith on 06/30/2023, at which time LPA Smith conducted a physical plant tour at around 11:00 am and conducted an interview with the administrator at approximately 10:30 am.

On 07/03/2023 this case was referred to the Community Care Licensing Investigations Branch (IB). Investigator Olivia Spindola continued the investigation by conducting records review and interviews on 07/14/2023,07/24/2023, 08/07/2023, 09/26/2023,09/27/2023 and 09/28/2023.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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-20230703102331

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 GARDENS OF TARZANA	FACILITY NUMBER: 197606676
	VISIT DATE: 01/29/2024

NARRATIVE

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(Cont from 9099)

Staff interviews conducted on 07/24/2023 at 11 am, revealed that upon admission to the facility, Resident #1 (R1) required help with all ADLs (Activity of Daily Living). R1 is wheelchair bound and staff uses a Hoyer Lift to transfer R1 to and from their wheelchair and bed. R1 only able to feed themself and used a wheelchair to get around the facility.

Interviews with staff and interested parties conducted within the same day on 07/14/2023, revealed that staff had noticed R1s legs were bruised, swollen and painful to the touch. Facility progress notes revealed that R1 sustained fractures t o their right tibia and fibula sometime between 06/16/2023 and 06/17/2023 and on 06/17/23 at 5:42 pm R1’s legs observed to be bruised, decolored and swollen. However, staff had no knowledge of how R1 sustained injuries. No one reported a fall incident involving R1. Information received revealed that although staff noticed swollen areas and discoloration on R1’s legs, staff failed to notify the family about R1’s condition and further investigate the cause of injuries.

On 06/18/2023, during evening hours, via zoom meeting, staff told interested parties that R1 was not getting better and “R1 also had tiny bruises on their arms.” A few hours later R1 was hospitalized after interested party came to the facility and called 911. On 06/23/23, R1 was return to the facility and no X-rays were done at the hospital. On 06/27/23 X-rays were ordered by R1’s doctor, and it was determined that R1’s swollen legs and discoloration were due to R1’s fracture of left fibula and tibia. Based on medical record review, R1 suffered from fracture and bruises, which could be a consequence from the fall and/or improper transfer assistance.

Based on interviews, observation and medical record review, there is a sufficient information to conclude that resident sustained unexplained injuries due to neglect and/or improper care and supervision.

Therefore, the allegation is SUBSTANTIATED at this time. Deficiencies issued per CA Code of Regulations, Title 22. See LIC9099D.

Exit Interview conducted. Copy of report given.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230703102331

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 GARDENS OF TARZANA	FACILITY NUMBER: 197606676
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/29/2024 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	Basic Services. (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs […] and providing the other basic services […] either directly or through outside resources.	1 2 3 4 5 6 7	Licensee shall submit a written plan describing how the staff shall prevent injuries to residents in care and what action staff will take to ensure that facility residents receive proper care and supervision. Licensee shall submit to CCL no later than 01/31/24
	8 9 10 11 12 13 14	This requirement is not met as evidenced by. The Licensee did not take required action to ensure that facility resident received proper care and supervision. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC9099 (FAS) - (06/04)

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