197604926-12-7-2022-31-AS-MCAA-CLVU5P-20221207141705

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604926
Report Date: 12/07/2022
Date Signed: 12/07/2022 02:17:15 PM

Document Has Been Signed on 12/07/2022 02:17 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:	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:	12/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Jose Bista, Nelly De La Cruz		TIME COMPLETED:	02:30 PM

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	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff Jose Bista and Nelly De La Cruz. They were advised of the reason for the visit. At approximately 11:20am, with the assistance of staff, LPA took a tour of the physical plant. The facility is a one story building with five (5) bedrooms and three (3) bathrooms. Required postings were observed in the entry area. The LPA's temperature was taken at entry. The smoke alarms are hardwired and interconnected. There is a carbon monoxide detector installed in the hallway by resident rooms that functions properly. The fire extinguisher is located by the kitchen. The charge date is 5/16/2022. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Bedrooms: There were four (4) bedrooms designated for residents' use, and one (1) bedroom designated for staff. Bedrooms #1 and #2 are private rooms, and bedrooms #3 and #4 are shared. All four bedrooms occupied by the residents were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are three (3) bathrooms designated for residents' use. All three bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 119 degrees Fahrenheit. Cleaning supplies that are stored in the bathrooms were observed under the sink, locked and inaccessible to the residents in care. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: TARZANA MANOR	FACILITY NUMBER: 197604926
	VISIT DATE: 12/07/2022

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

Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use in the backyard. The outdoor area was free of hazards. The laundry area is located adjacent to the kitchen. Detergents were observed inaccessible to the residents. There is also a door that would keep residents out.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were observed locked in a designated hallway closet. The medication records were reviewed for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit Interview Conducted and a Copy of this Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2