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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610638
Report Date: 06/05/2025
Date Signed: 06/05/2025 04:15:16 PM

Document Has Been Signed on 06/05/2025 04:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CHATSWORTH COMMONS SENIOR LIVING, LLCFACILITY NUMBER:
197610638
ADMINISTRATOR/
DIRECTOR:		MONROY, DAVIDFACILITY TYPE:
740
ADDRESS:20801 DEVONSHIRE ST.TELEPHONE:
(323) 902-6000
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 268CENSUS: 115DATE:
06/05/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:David Monroy, Adminitrator TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Angela Panushkina and Licensing Program Manager (LPM), Nichelle Gillyard conducted a Pre-Licensing Inspection and met with the Administrator/Applicant, David Monroy. This is a Change of Ownership Application from facility "BROOKDALE CHATSWORTH" to CHATSWORTH COMMONS SENIOR LIVING, LLC. An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 05/07/2025. A Fire Clearance was approved on 09/05/2025 for a total capacity of 268, of which 134 Ambulatory, 124 Non-ambulatory and 10 can be Bedridden in rooms #107,111,119,121,123,127,161,163,
165 & 167.

Facility is a two (2) story building. However, the rooms on a second level are numbered from 200-400. There is no 3rd or 4th level. In the main entrance of the building there is a cafe that is a self-serving refreshment and snack area with seating. The main living room has seating and a grand piano for entertainment. Today's site visit consisted of LPA/LPM touring the physical plant inside and outside and observed the following:

KITCHEN: The main kitchen that prepares all the meals for the facility is located on the first floor. The kitchen is fully stocked with perishable and nonperishable foods. The kitchen work area surface appeared clean, and no food items are stocked with cleaning supplies. Food is restocked regularly at least 2 times a week. The residents with special dietary needs are posted in the kitchen prep area with pictures of the resident and their food choices or required preparation. Sharp knives/objects observed to be locked and inaccessible to residents in care.
Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: CHATSWORTH COMMONS SENIOR LIVING, LLC
FACILITY NUMBER: 197610638
VISIT DATE: 06/05/2025
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 BEDROOMS: There are 173 bedrooms designated for residents’ use. LPA/LPM observed the facility's model room in addition during the tour LPA/LPM observed unoccupied, empty rooms and rooms occupying residents. The bedrooms have sufficient closet space. Resident room was observed to be clean and sanitary.

COMMON AREAS: The facility maintains a comfortable temperature at 72°F. The Common areas are furnished with adequate furniture to accommodate a maximum capacity of 268 residents. These included a living room furniture, a television, tables and chairs and a dining area. There is a functioning telephone on the premises. LPA/LPM observed license to be posted in a conspicuous area along with the complaint poster and personal rights, including other required postings. Smoke and carbon monoxide detectors were located throughout the facility, and at 11:30am they were tested and observed to be operational. LPA/LPM also observed fire extinguishers located throughout and outside of the facility, and they were last serviced on 03/06/2025. A fire inspection is conducted every year on the operation of the sprinkler system, electrical panels, water heaters, fire extinguishers, manual pull alarms, carbon monoxide detector and smoke detector. Copy of the inspection report was given to LPA.

LAUNDRY ROOM: The laundry room is located downstairs and upstairs. The washers/dryers appear to be in good condition. Laundry supplies are kept locked and inaccessible to residents in care

MEDICATION ROOM: The Med-room is located on a 1st floor by the room #159. The facility also has four (4) MedCarts that were observed to be locked and inaccessible to residents.

SURROUNDING GROUNDS: The driveway serves as a large parking lot for guests for drop-off purpose only. The back of the facility has sufficient yard space. LPA/LPM observed appropriate outdoor furniture, with a covered shaded area for the residents. No bodies of water.

Component III was conducted at 1:00pm. LPA/LPM discussed the following which include but is not limited to Component III; care and supervision, reporting requirements, preplacement, criminal record, food service, medications and maintaining physical plant and resident/staff records. LPA/LPM clarified if the facility will be admitting or advertising Dementia Care. LPA/LPM were informed that there is no current plan. The status is: To-be-determined.

OTHER: LPA/LPM Reviewed Certificate of Occupancy and it is clear that 1st floor is for Non-Ambulatory and 2nd floor Ambulatory residents only.
Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: CHATSWORTH COMMONS SENIOR LIVING, LLC
FACILITY NUMBER: 197610638
VISIT DATE: 06/05/2025
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The applicant will be given 10-days to submit the following before the facility can be licensed:

· LIC610E with the name and licence number indicated from this report: CHATSWORTH COMMONS SENIOR LIVING, LLC (#197610638)

· Infection Control Plan with the name and licence number indicated from this report: CHATSWORTH COMMONS SENIOR LIVING, LLC (#197610638)

· Floor Plan with the name and licence number indicated from this report: CHATSWORTH COMMONS SENIOR LIVING, LLC (#197610638)

Exit interview conducted and copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC809 (FAS) - (06/04)
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