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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606676
Report Date: 06/23/2021
Date Signed: 06/23/2021 03:59:52 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 GARDENS OF TARZANAFACILITY NUMBER:
197606676
ADMINISTRATOR:MNATSAKANYAN, LILITFACILITY TYPE:
740
ADDRESS:18700 BURBANK BLVDTELEPHONE:
(818) 342-0003
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:90CENSUS: 46DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lilit MnatsakanyanTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced annual required visit. LPA met with the administrator and explained the reason for this visit.

LPA conducted a physical plant tour which included facility common areas, dining areas, common area bathrooms, and random resident bedrooms. LPA observed the proper signs all throughout the facility regarding hand washing and staying six feet apart. LPA observed residents to be wearing mask throughout the facility. LPA observed all common areas to be appropriately furnished along with hand sanitizer stations located throughout the facility. Smoke alarm is hard wired and was operating along with the carbon monoxide detector. Resident bedrooms were appropriately furnished.
No deficiencies cited. Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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