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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602414
Report Date: 06/18/2021
Date Signed: 06/18/2021 12:47:25 PM

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:BROOKDALE NORTH TARZANAFACILITY NUMBER:
197602414
ADMINISTRATOR:DANA ANDERSONFACILITY TYPE:
740
ADDRESS:5711 RESEDA BLVDTELEPHONE:
(818) 996-2022
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:135CENSUS: 60DATE:
06/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Nananne EichermuellerTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Martina Berry conducted a Required Annual visit at the facility. The LPA met with Business Office Manager Nananne Eichermueller to conduct the entrance interview and explain the reason for the visit.

The LPA started the facility tour at 11:25 AM. The facility currently has 60 residents. The majority of residents and staff were fully vaccinated as of March 2021. The facility conducts weekly testing for unvaccinated staff. The facility currently has no active cases of COVID-19. N95 fit testing was completed for all staff.

The LPA toured all areas of the facility including, but not limited to common areas, bathrooms, activity rooms, kitchen, medication room, and visitation areas. COVID-19 and infection control signage is posted throughout the facility. Hand sanitizing stations are located throughout the facility. Restrooms are fully stocked with soap and hand washing supplies. Meals are offered in the facility's dining areas.Social distancing is implemented in each dining area by reducing capacity distancing tables. Dining areas are sanitized in between groups. Distancing procedures have also been implemented for group activities.

The LPA reviewed the facility's infection control plan. The facility is sanitized during each shift. Common areas are cleaned at least every 2 hours. Resident rooms are sanitized weekly or as needed. Residents are screened at least every shift for COVID-19 symptoms. The facility keeps at least 30 days supply of medication for each resident. Residents and staff are required to wear PPE while in the facility. PPE inventory is completed weekly. Residents that test positive for COVID-19 are isolated in a private room with designated staff to complete regular monitoring. Residents that test positive for COVID-19 and, are under isolation, are monitored at least every 4 hours or as needed. Isolation bins with PPE supplies are made available for each isolation room.
(Continued on LIC809-C)
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Martina BerryTELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
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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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: BROOKDALE NORTH TARZANA
FACILITY NUMBER: 197602414
VISIT DATE: 06/18/2021
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There are designated visiting areas located throughout the facility, located indoors and outdoors. Residents may also have visitors in their private rooms. A sign-in policy, temperature check, and COVID-19 questionnaire has been implemented for all visitors. Residents are provided with infection control updates during resident council meetings and newsletters. Information updates are also posted for residents to review. Infection control updates are provided to staff during monthly staff meetings or more often if needed. Topics include review of Provider Information Notices (PINs), PPE requirements, return to work policies, and changes in state/county requirements.

No deficiencies cited. An exit interview was completed with Business Office Manager Nananne Eichermueller. A copy of this report was provided via email.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Martina BerryTELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
LIC809 (FAS) - (06/04)
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