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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609991
Report Date: 06/01/2021
Date Signed: 06/01/2021 11:02:51 AM

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 ASSISTED LIVINGFACILITY NUMBER:
197609991
ADMINISTRATOR:CHILIAN, HRIPSIMEFACILITY TYPE:
740
ADDRESS:5912 CAHILL AVETELEPHONE:
(818) 429-0797
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:6CENSUS: 5DATE:
06/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Valiant & Joy PoTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility 9:15am to conduct an unannounced infection control inspection/visit. Upon arriving, LPA was greeted by caregiver Valiant Po outside of the facility; who allowed LPA to enter the facility. According to Valiant, there have not been any active or past COVID cases at the facility, and staff and residents have been vaccinated. The current census is (5). As LPA and caregiver entered through the back door of the facility, LPA temperature was taken, and LPA observed the visitors sign in sheet and cleaning table, with hand sanitizer. LPA observed both staff to have full mask covering. COVID-19, CDC, Department of Public Health, and Licensing postings on the walls throughout the facility. Caregiver Joy contacted Administrator Hripsime Chilian, who LPA spoke to over the facility telephone. LPA observed staff preparing breakfast, and (1) resident at the kitchen table eating.

The infection control inspection began with the caregiver Joy, who escorted LPA throughout the facility. The facility has (7) private bedrooms; with (1) room for staff. All bedrooms were properly furnished; with a COVID-19 posting on each resident's bedroom door. The common areas were observed to be clean, including bathrooms, with soap and towels, and hand washing signs visually posted. LPA conducted a mitigation plan review with the caregiver Joy, and telephonically with Administrator, to obtain information on how the facility has implemented the department's mitigation plan.

The Administrator reported to LPA, the facility has documentation of all vaccination records and other pertinent information pertaining to COVID-19, in staff and resident files. All new employee hires and new resident admits, will be properly screened and provided a negative COVID test, prior to entering the facility. Administrators reported to reading the departmental emails, and continues to provide and conduct training to staff in relation to COVID-19. There is currently no paid sick leave policy in place. LPA discussed with the Administrator, that even though, everyone in the facility has been vaccinated, there needs to be a sick leave policy in place for staff, that is flexible and not punitive. The Administrator informed LPA that she would begin to develop a policy and discuss with staff. The facility does not have staffing issues, due to having a plan in place. There are designated rooms for potential positive COVID residents, because the facility has private rooms.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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 ASSISTED LIVING
FACILITY NUMBER: 197609991
VISIT DATE: 06/01/2021
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PPE supplies were inspected, and Administrator reported to LPA that the supplies are kept at a different location and replenished as often as needed, based on the request of staff. Chemicals, cleaning supplies, paper products were observed and locked and secured. Administrator informed LPA that they continue to implement the best practices for their facility; which has kept them COVID-19 free. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview was conducted with caregivers, and copy of report will be emailed to Administrator, who will provide a signature of the report, and email back to LPA. This procedure is used to continue implementing safe measures surrounding the situation of the Coronavirus Disease 2019 (COVID-19).

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
LIC809 (FAS) - (06/04)
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