Brookdale Gardens of Tarzana

Type of visit: Required - 1 Year

At 8:45 a.m. on 07/03/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the interim Executive Director (ED) and disclosed the reason for the visit. The facility was last visited on 06/06/25 for a complaint visit. It is a two story building with eighty-three (83) private and shared bedrooms, private and shared bathrooms, kitchen, dining area, common areas, activity areas, exercise room, offices, beauty salon, theatre, laundry room, and outdoor areas. It has an approved fire clearance for ninety (90) nonambulatory residents. Approved hospice waivers for five (05). Near the main entrance and mail room, LPA observed postings for confidential complaint contacts, Ombudsman contacts, emergency disaster plan, facility license and sketch, theft and loss policy, personal rights, rights of resident councils, admission agreement, transportation schedule, activity schedules, and daily menus. Walls, floors, windows, screens, and blinds were clean and in good repair. Coffee, water, and snacks were available near the lobby. Surveillance cameras were observed on the exterior and in common areas. The facility has two (02) elevators. Both were in working order. Resident mailboxes were located near the main entrance near staff offices. The laundry room was locked and contained two (02) operable washers, two (02) operable dryers, and detergents. Interview with the ED around 9:10 a.m. today revealed some cameras are used by families in resident rooms with no audio. Exits are secured with keypad locks. At approximately 9:30 a.m. LPA measured the room temperature to be 73 degrees Fahrenheit. The fireplace was appropriately covered. Hand sanitizer stations are posted throughout the facility on both floors. At approximately 9:40 a.m. LPA observed fully charged fire extinguishers on the first and second floor hallways which were last inspected on 10/11/24. Flashlights were also placed in each fire extinguisher housing for emergency lighting purposes. At approximately 9:45 a.m., smoke and carbon monoxide detectors within rooms were tested and deemed operational. Emergency exits were illuminated, unlocked, and free from obstructions. The facility has private and shared bedrooms. Bedrooms are furnished by residents and contain a chair, lamp, nightstand, storage, pull cords in the bedroom and bathroom, private bathrooms, and a bed with adequate bedding. All furnishings were clean and in good condition. The facility has private and shared bathrooms. Private bathrooms in rooms contained liquid soap, paper towels, trash cans with a tight fitting lid, grab bars near the toilet and shower pull cords, and a non-skid surfaces in the shower. All shared bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet, and pull cords. LPA observed an adequate supply of perishable, non-perishable, and emergency foods and water in the kitchen. Additional emergency water was stored in an upstairs storage closet. The hood was clean. Appliances were in good condition. Resident dietary cards were posted. At approximately 10:00 a.m., walk-in refrigerator and freezer temperatures were measured to be 39 and -12 degrees Fahrenheit, respectively. The dining room contained furniture in good repair, a suggestion box, and daily and alternate menus. A covered patio area adjacent to the dining room contained furniture in good condition, a designated smoking area, self-locking exits, and a gas grill. There was also a rose garden outdoor space available. At 11:10 a.m. and 12:10 p.m., call system pull cords were tested in first and second floor public restrooms. Staff responded within one (01) and two (02) minutes of each request. At approximately 11:15 a.m. and 12:15 p.m. LPA measured first and second floor water temperatures to be within regulatory range. The upstairs gym contained exercise equipment in good condition. The Beauty Salon, electrical rooms, janitorial closets, and storage closets were all locked an inaccessible. The theatre contained movies, television, and furniture in good repair. Board games, puzzles, art supplies, and reading materials were provided in upstairs and downstairs activity areas. A computer with internet, microphone, and camera was available for resident use on the second floor. The facility uses secured medication carts on each floor to assist with medications. The medication room is locked and contained medical records and a complete first aid kit with tweezers, scissors, bandages, and digital thermometer. A medication review was conducted at approximately 12:30 p.m. All prescription medications and controlled substances were present in correct quantities. At approximately 12:45 p.m. LPA reviewed the most recent fire safety inspection from 09/04/24. All fire safety systems passed inspection. All staff and resident files were complete and available for audit. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 3, 2025

Allegation investigated: Staff unlawfully evicted a resident Staff coerced a client to sign unauthorized notice while in care

At approximately 8:45 a.m. on 06/06/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit. Prior to this investigation, LPA reviewed the eviction notice of Resident #1 (R1) at approximately 4:00 p.m. on 05/01/25. To further investigate the allegations, LPA conducted an initial visit on 05/08/25 and toured the facility inside and out at 2:05 p.m., interviewed staff between 2:15 p.m. and 2:45 p.m., and conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, and staff and client rosters at 2:45 p.m. Today, LPA and toured the facility inside and out at 8:50 a.m., interviewed staff between at 9:20 a.m. and 10:00 a.m., and conducted a record review of eviction-related paperwork and emergency contacts at 9:30 a.m. Unsubstantiated Regarding the allegation "Staff unlawfully evicted a resident" it was alleged R1 was evicted unlawfully. Record review of the eviction notice revealed the facility issued R1's eviction on 04/30/25 which met all requirements of Title 22, Division 6, Chapter 8, Article 4, Subsection 87224 Eviction Procedures. Interview with Staff #1 (S1) at 2:15 p.m. on 05/08/25 confirmed that the eviction notice was hand-delivered to R1 on 04/30/25. Additionally, the eviction notice was sent via certified mail to R1’s representative and faxed the notice to Community Care Licensing in a timely manner. LPA reviewed an Affidavit of Hand Delivery which R1 signed and confirmed receipt of the eviction notice with the Executive Director and S1. LPA also reviewed the certified mail receipt from 04/30/25 sent to R1’s representative at the address provided. Interview with Staff #2 (S2) at 2:40 p.m. on 05/08/25 also confirmed that the eviction notice was hand-delivered to R1 and sent via certified mail to their representative. Based on interviews and record review, the staff did not unlawfully evict R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff coerced a client to sign unauthorized notice while in care " it was alleged staff coerced R1 to sign a 30-day eviction notice. LPA did not interview R1 at the request of their representative. Interview with S1 revealed R1 voluntarily signed the notice of hand-delivery. S1 noted R1’s signature was requested for the facility’s due diligence in ensuring all parties received the notice in a timely manner. Record review of the Affidavit of Hand Delivery from 04/30/25 revealed that the notice stated the Executive Director served the 30-day notice to pay or quit for amounts due from October 2024 to April 2025. Based on interviews and record review, although the allegation is valid, the investigation yielded no evidence of coercion of R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 6, 2025 · control 31-AS-20250504210228

Type of visit: Case Management - Incident

At approximately 1:00 p.m. on 01/29/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the administrator and disclosed the reason for the visit. Today’s case management was conducted after the Woodland Hills-South Regional Office received two (02) suspected abuse reports from the facility. The first report alleged that during the evening of 01/25/25, Staff #1 (S1) handled Resident #1 (R1) in a rough manner. The second report alleged that Staff #2 (S2) “performed inappropriately” when caring for Resident #2 (R2) around the morning of 01/25/25. To investigate the allegations above, LPA interviewed the administrator and staff between 1:10 p.m. and 3:00 p.m. today, conducted a record review of pertinent records, including but not limited to medical assessments, and staff and client rosters at 1:30 p.m., and toured the facility inside and out at 1:50 p.m. Interview with R1 today at 2:40 p.m. revealed they were pushed and handled roughly by S1. Interview with the administrator at 1:10 p.m. today revealed they investigated the allegations and suspended S1 and S2 as a safety measure. The administrator stated S1 and S2 had good relationships with facility staff and residents and had no previous allegations involving them. Interviews with Staff #3 (S3) at 1:45 p.m. and Staff #4 (S4) at 2:20 p.m. today confirmed both S1 and S2 were nice and had no previous incidents or allegations. Telephonic interview with S1 today at 1:55 p.m. today revealed that they had a good relationship with R1 and never abused them. The administrator also stated that S2 was not at work during the time that the abuse was alleged. Record review of S2’s time card confirmed they were not working during the time and date the abuse was alleged. Since R2 was relocated to another facility on 01/28/25, S2 returned to work today. Interview with S2 at 1:30 p.m. today confirmed they were not at work between 01/23/25 and 01/25/25 and they had never abused any residents. Since R2 could not be contacted, the allegations need further investigation. LPA to follow up with additional investigation at a future date. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 29, 2025

Type of visit: Required - 1 Year

At 9:00 a.m. on 06/19/2024, Licensing Program Analysts (LPAs) Nicholas Reed and Leizl delaCerra conducted an unannounced annual inspection. LPAs met with staff and later the Executive Director (ED) and disclosed the reason for the visit. LPAs and ED toured the facility inside and out. The facility was last visited on 12/13/2023 for a case management visit. It is a two story building with eighty-three (83) private and shared bedrooms, private and shared bathrooms, kitchen, dining area, common areas, activity areas, exercise room, offices, beauty salon, theatre, laundry room, and outdoor areas. It has an approved fire clearance for ninety (90) nonambulatory residents. Approved hospice waivers for five (05). A file review was conducted prior to this visit. LPAs observed postings for confidential complaint contacts, Ombudsman contacts, emergency disaster plan, facility license and sketch, theft and loss policy, personal rights, and rights of resident councils near the mailboxes at the front. Additional postings were observed inside for a transportation schedule, activity schedules, and daily menus. The parking lot is located in the rear of the facility. Surveillance cameras were placed on the exterior and in common areas. Exits are secured with keypad locks. At 10:00 a.m., approximately fifteen (15) residents were observed participating in exercise activities in the main activity area. The facility has private and shared bedrooms. Bedrooms are furnished by residents and contain a chair, lamp, nightstand, storage, pull cords in the bedroom and bathroom, mini fridge, microwave, private bathrooms, and a bed with adequate bedding. All furnishings were clean and in good condition. The facility has private and shared bathrooms. Private bathrooms in rooms contained liquid soap, paper towels, trash cans with a tight fitting lid, grab bars near the toilet and shower pull cords, and a non-skid surfaces in the shower. All shared bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet, and pull cords. At approximately 10:15 a.m. LPAs measured the room temperature to be 72 degrees Fahrenheit. Walls, floors, windows, screens, and blinds were clean and in good repair. The fireplace was appropriately covered. Hand sanitizer stations are posted throughout the facility on both floors. At approximately 10:30 a.m. LPAs observed fully charged fire extinguishers on the first and second floor hallways which were last inspected on 06/11/24. Flashlights were also placed in each fire extinguisher housing. At approximately 11:00 a.m., smoke and carbon monoxide detectors were tested and operational. At 11:13 a.m. and 11:35 a.m., call system pull cords were tested in Room #210 and Room #110. Staff responded within three (03) minutes each time. Between 11:15 a.m. and 11:35 a.m. LPAs measured water temperatures in first and second floor rooms to be 112.5, 106.5, and 119.0 degrees Fahrenheit. The upstairs gym contained exercise equipment in good condition. The Beauty Salon, electrical rooms, and storage closets containing cleaning supplies, PPE, and confidential files were all locked. The theatre contained movies, television, and furniture in good repair. Board games, puzzles, and reading materials were provided in both activity areas. A computer with internet, microphone, and camera was available for resident use on the first floor. Signs indicating “No Smoking – Oxygen in Use” were placed appropriately in hallways. The facility uses secured medication carts on each floor to assist with medications. The medication room is locked and contained medical records and a complete first aid kit with tweezers, scissors, bandages, and digital thermometer. LPA observed an adequate supply of perishable, non-perishable, and emergency foods and water in the kitchen. The stove hood was clean. Appliances were in good condition. Resident dietary cards were posted. At 11:51 a.m. and 11:53 a.m., walk-in refrigerator and freezer temperatures were measured to be 38 and -5 degrees Fahrenheit. The locked laundry room near the kitchen contained two (02) washing machines and two (02) dryers. Both were in working order. LPAs observed two (02) covered patio areas in the rear of the facility. They contained furniture in good condition, gardened areas, a designated smoking area, self-locking exits, and a gas grill. All emergency exit paths were free from obstructions. During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jun 19, 2024

Allegation investigated: Personal Rights

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 (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.the state’s words, verbatim · CDSS document, Jan 29, 2024 · control 31-AS-20230703102331

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Jan 29, 2024

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. 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.the state’s words, verbatim · CDSS document, Jan 29, 2024

Plan of correction: 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

Type of visit: Case Management - Incident

At 9:45 a.m. on 12/13/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the executive director and disclosed the reason for the visit. Today’s case management visit was conducted after the Woodland Hills-South Adult and Senior Care Regional Office received a report and an SOC341 from the facility of a staff member, Staff #1 (S1), handling Resident #1 (R1) in a rough manner. The Executive Director sent the reports at approximately 3:00 p.m. on 12/06/2023 after reviewing video footage of the incident. The reports detailed that at approximately 12:30 p.m. on 12/02/2023, S1 was pushing R1 in their wheelchair. R1 told S1 they did not want to go to the bathroom and planted their feet. S1 continued to push R1 and R1 fell forward. The facility evaluated R1 for injuries and no injuries have been reported. Today, LPA interviewed the executive director at 9:50 a.m., the health and wellness coordinator at 9:55 a.m., reviewed video footage of the incident at 10:00 a.m., toured the facility at 10:05 a.m., and reviewed records including but not limited to R1’s emergency contact list, medical assessment, service plan, and S1’s employee file. LPA was unable to interview R1 at 10:15 a.m. due to a prior engagement. The executive director informed the LPA that S1 is currently suspended from working at the facility. The facility is conducting an internal investigation and LAPD have an ongoing investigation. Due to the need for more information, LPA will return at a future date to resolve the matter. No immediate health and safety hazards were observed during this visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 13, 2023