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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606676
Report Date: 07/06/2023
Date Signed: 07/06/2023 03:37:52 PM


Document Has Been Signed on 07/06/2023 03:37 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:BROOKDALE GARDENS OF TARZANAFACILITY NUMBER:
197606676
ADMINISTRATOR:HELEN LEEFACILITY TYPE:
740
ADDRESS:18700 BURBANK BLVDTELEPHONE:
(818) 342-0003
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:90CENSUS: 49DATE:
07/06/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Amanda MonroyTIME COMPLETED:
03:40 PM
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Licensing Program Analysts (LPA) Tihesha Smith made an unannounced Case Management - Annual Continuation visit to this facility to complete the Required 1-year visit initiated on 07/05/2023. Upon arrival LPA met with the administrator.

During the initial visit on 07/05/2023 there were no deficiencies noted, however due to time constraints and computer issues LPA Smith was unable to complete the care tools, and interview staff and residents.

On today’s visit LPA Smith conducted interviews with staff and residents from approximately 10:50 am-1:50 pm. Annual visit completed/No deficiencies noted.

Exit interview conducted. Copy of report emailed.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
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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