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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604926
Report Date: 12/30/2025
Date Signed: 12/30/2025 11:40:50 AM

Document Has Been Signed on 12/30/2025 11:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MANORFACILITY NUMBER:
197604926
ADMINISTRATOR/
DIRECTOR:		DINA F. PAMATMATFACILITY TYPE:
740
ADDRESS:18162 RANCHO STREETTELEPHONE:
(818) 807-3050
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 6CENSUS: 4DATE:
12/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Dina PamatmatTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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At approximately 8:45 a.m. on 12/30/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the licensee and disclosed the reason for the visit.

A file review was conducted prior to today’s visit.

The facility was last visited on 11/26/24 for a complaint visit. It is a single story building with five (05) bedrooms, three (03) bathrooms, kitchen, laundry room, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which five (05) may be bedridden. Approved hospice waivers for five (05).

LPA observed a maintained front yard. Postings at the front and in the hallway included COVID precautions, facility license, confidential complaints contacts, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights, and the facility sketch.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 8:55 a.m. LPA measured the room temperature to be 76 degrees Fahrenheit. Two (02) residents were observed in the dining room watching television. Two (02) staff members were observed cleaning and preparing lunch.

The living room contained a television, reading material, exercise equipment, and furniture in good repair. A fireplace was appropriately covered and turned off. Medications were locked near the main entrance and under the counter.

The facility has five (05) bedrooms. One (01) bedroom is designated as a staff room. The staff room was unlocked and free of hazards.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2025
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TARZANA MANOR
FACILITY NUMBER: 197604926
VISIT DATE: 12/30/2025
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All bedrooms contained a chair, lamp, nightstand, storage, bell or call system, and a bed with adequate bedding. All furnishings were clean and in good condition. All rooms had hospital beds with wheels in the locked position.

The facility has three (03) bathrooms. Two (02) bathrooms are private to Bedrooms #3 and #4, and one (01) is shared. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, commodes, and a non-skid mat in the shower. At approximately 9:30 a.m. LPAs measured the water temperature in the shared bathroom to be 106.2 degrees Fahrenheit. Interview with Staff #1 (S1) at 9:35 a.m. today revealed chemicals were stored below the sink, but the lock recently broke, so all chemicals are stored near the laundry area.

LPA heard the house telephone ring at 9:40 a.m. The phone was deemed operational. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. Appliances were in good condition. Sharps were locked under the counter. The stove surface and hood were clean. A washing machine and dryer were located in the laundry area. Both were in working order. Detergents and cleaning supplies were locked near the appliances.

LPA observed a shaded patio area in the rear of the facility. The patio contained furniture in good condition. A fence on the southeast side of the facility was falling into the neighbor’s yard. Interview with the licensee at approximately 11:00 a.m. revealed the neighbor next door is new and is responsible for fixing the fence. The licensee has a plan to restore the fence properly.

All emergency exit paths were free from obstructions. Two (02) out of two (02) exit gates were unlocked. Four (04) out of four (04) auditory alarms were turned on and functioning. Fire sprinklers were located throughout the facility. At 11:30 a.m., smoke and carbon monoxide detectors were tested and operational. At approximately 11:35 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last tested on 05/16/2024 with a tag attached.

At approximately 11:00 a.m. LPA reviewed staff and resident files. All files were complete and available for audit.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health or safety hazards were observed.

Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2025
LIC809 (FAS) - (06/04)
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