197609918-1-27-2023-31-AS-MCAA-CNGQN5-20230127111834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609918
Report Date: 01/27/2023
Date Signed: 01/27/2023 11:18:45 AM

Document Has Been Signed on 01/27/2023 11:18 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TARZANA SENIOR LIVING INC		FACILITY NUMBER:	197609918
ADMINISTRATOR:	AYVAZYAN, SARGIS		FACILITY TYPE:	740
ADDRESS:	5236 OTIS AVE		TELEPHONE:	(747) 253-0007
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY: 6		CENSUS: 6	DATE:	01/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Bert Mariano Sargis Ayvazyan		TIME COMPLETED:	11:20 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Bert Mariano and explained the reason for the visit. The administrator, Sargis Ayvazyan joined shortly after. At approximately 9:20am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are battery operated. There are carbon monoxide detector installed in the hallway that function properly. There is a fully charged fire extinguisher located in the kitchen. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Bedrooms: There were six (6) bedrooms designated for residents' use. All rooms are for private use. LPA observed all rooms to be properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are three (3) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105 degrees Fahrenheit. LPA did not observe cleaning supplies or any hazardous material stored underneath the bathroom sink, or anywhere else in the bathroom. Common Areas: These included the living room and dining area. The common areas were properly furnished. The floors were clean. The furniture was maintained and in good condition. There is a fireplace, but it is non-operational, screened and key to ignite is not accessible. Hallways and exits were clear of obstruction. The auditory alarms on exit doors were on and functional at the time of the visit.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TARZANA SENIOR LIVING INC	FACILITY NUMBER: 197609918
	VISIT DATE: 01/27/2023

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC809 (FAS) - (06/04)

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