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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608477
Report Date: 05/24/2022
Date Signed: 05/24/2022 12:57:12 PM


Document Has Been Signed on 05/24/2022 12:57 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:SUNRISE ASSISTED LIVING OF STUDIO CITYFACILITY NUMBER:
197608477
ADMINISTRATOR:SHAHIN TAGHIZADEHFACILITY TYPE:
740
ADDRESS:4610 COLDWATER CANYON AVETELEPHONE:
(818) 505-8484
CITY:STUDIO CITYSTATE: CAZIP CODE:
91604
CAPACITY:121CENSUS: 67DATE:
05/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Sean TaghizadehTIME COMPLETED:
01:00 PM
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At approximately 12:00 p.m. on 05/24/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit due to a recent incident. LPA met with the Executive Director and disclosed the reason for the visit.

The facility submitted a Special Incident Report on 05/17/2022 regarding Resident #1 (R1) who left the facility without staff supervision. The report stated a ‘Samaritan’ found R1 with a nose bleed a few miles from the facility.

At 12:16 p.m. LPA reviewed R1’s medical assessment and plan of care. At 12:20 p.m. LPA interviewed the Executive Director on the cause of the incident and the steps the facility has taken to prevent the incident from reoccurring. R1 and their POA were informed of the facility’s sign out policy. R1 was eating lunch and unavailable for an interview at the time of visit.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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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