197604926-3-5-2024-31-AS-MVAO-D45TY4-20240408150803

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197604926
Report Date: 03/05/2024
Date Signed: 03/05/2024 01:11:17 PM

Substantiated

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:	03/05/2024
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Dina Pamatmat		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Staff did not ensure that resident's records were maintained as necessary

INVESTIGATION FINDINGS:

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At 11:20 a.m. on 03/05/2024, Licensing Program Analysts (LPAs) Nicholas Reed and Raymond Comer conducted an unannounced complaint visit. LPAs met with staff and later the administrator and disclosed the reason for the visit.

To investigate the allegation above, LPAs interviewed the administrator and staff between 11:20 a.m. and 12:30 p.m. today and reviewed records pertinent to the investigation at 12:00 p.m. today including but not limited to an admission agreement, medical assessment, identification form, and consent forms.

Regarding the allegation “Staff did not ensure that resident's records were maintained as necessary” it was alleged the records of Resident #1 (R1) were not provided to emergency responders when requested. Interview with Staff #1 (S1) at 11:45 a.m. today revealed that R1 was hospitalized on 02/14/2024.

Substantiated

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: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

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 4

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: 03/05/2024

NARRATIVE

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Emergency responders took R1’s complete file with them and did not return the file to the facility. The facility attempted to obtain the files from the emergency responders and the hospital but was unsuccessful. Emergency responders came again for R1 on 02/26/2024 and were unable to obtain R1’s files. Record review today revealed R1 had an incomplete medical assessment which was needed by emergency responders. Based on interviews and record review, the facility did not ensure the R1’s records were maintained at the facility. Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is issued on the attached LIC 809-D page.

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: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/05/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/15/2024 Section Cited CCR 87468.2(a)(2)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee has agreed to acquire a new copy machine to maintain and provide all resident records.
	8 9 10 11 12 13 14	Based on record review and interview, the licensee did not comply with the section cited above in one (01) out of five (05) residents which poses a potential Health, Safety, or Personal Rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

LIC9099 (FAS) - (06/04)

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