197604926-3-15-2024-31-AS-MVAO-D45TY3-20240408150803

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197604926
Report Date: 03/15/2024
Date Signed: 03/15/2024 10:05:02 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
02/29/2024 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20240229145911

FACILITY NAME:	TARZANA MANOR		FACILITY NUMBER:	197604926
ADMINISTRATOR:	DINA F. PAMATMAT		FACILITY TYPE:	740
ADDRESS:	18162 RANCHO STREET		TELEPHONE:	(818) 807-3050
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	6	CENSUS: 5	DATE:	03/15/2024
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Jose Aldeson		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not seek medical attention for resident in a timely manner

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 8:35 a.m. on 03/15/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with Staff #1 (S1) and disclosed the reason for the visit. The licensee called LPA at 10:00 a.m. to designate S1 to sing today's reports.

Regarding the allegation “Staff did not seek medical attention for resident in a timely manner” it was alleged facility staff did not provide timely care when Resident #1 (R1) was “in respiratory distress and septic”.

To investigate the allegation above, LPAs Reed and Comer interviewed the licensee and three (03) staff between 11:20 a.m. and 12:30 p.m. on 03/05/2024 and reviewed records pertinent to the investigation at 12:00 p.m. including but not limited to an admission agreement, medical assessment, identification form, and consent forms. Today, LPA reviewed hospital records of R1 at 8:45 a.m. and toured the facility at 9:50 a.m.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 31-AS-20240229145911

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TARZANA MANOR	FACILITY NUMBER: 197604926
	VISIT DATE: 03/15/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Interviews with three (03) out of three (03) staff and the licensee confirmed that R1 had no signs of infection, sepsis, or any symptoms of illness, no diagnosis of sepsis, and no physician’s order or prescription for antibiotics to address an infection. Interview with S1 at 11:20 a.m. on 03/05/2024 revealed R1 was last hospitalized on 02/12/2024. Record review at 12:00 p.m. on 03/05/2024 revealed R1 was admitted on 02/12/2024 for syncope and returned to the facility on 02/15/2024. R1 returned with two new physician’s orders for eye drops and a medication for heart arrhythmia. S1 confirmed R1 was assisted with all current and new medications. Around 11:00 p.m. on 02/26/2024, S1 and two (02) other staff noticed R1 having difficulty breathing. S1 called 9-1-1 and performed CPR until paramedics arrived. Record review of hospital records revealed R1 was admitted to Kaiser Woodland Hills around 2:30 a.m. on 02/27/2024 with low blood pressure and low blood oxygen levels. R1 was diagnosed with septic shock with pneumonia suspected as the source of the infection. Based on interviews and record review, facility staff followed all physician’s orders and sought medical attention promptly when R1 exhibited distress. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health and safety risks were observed during this visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2