197609991-6-27-2022-31-AS-MCAA-CFPTT2-20220624150000

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609991
Report Date: 06/24/2022
Date Signed: 06/27/2022 07:15:56 AM

Document Has Been Signed on 06/27/2022 07:15 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 ASSISTED LIVING		FACILITY NUMBER:	197609991
ADMINISTRATOR:	CHILIAN, HRIPSIME		FACILITY TYPE:	740
ADDRESS:	5912 CAHILL AVE		TELEPHONE:	(818) 429-0797
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	6	CENSUS: 3	DATE:	06/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Arlene Aragon		TIME COMPLETED:	03:00 PM

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, Arlene Aragon and explained the reason for the visit. At 10:45am, 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 hardwired and interconnected. There are carbon monoxide detectors that functions properly. The fire extinguisher is located in the kitchen. The charge date is 5/1/2022. 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. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: There were six (6) bedrooms designated for residents' use. Three of the bedrooms, in use by residents were were properly furnished with appropriate beddings and linens with sufficient lighting. The other three bedrooms were vacant and empty. Bathrooms: There are four (4) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 114 degrees Fahrenheit. Cleaning supplies are being stored in the hallway bathroom. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

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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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: 06/24/2022

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. The laundry area and detergents are located by the kitchen.

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, deficiencies were cited (refer to LIC 809-D).

Note that on June 1, 2022, licensee submitted written notice of their intent to sell their business. Residents and their families were notified within 60 days.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 06/27/2022 07:15 AM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

This requirement is not met as evidenced by: During inspection, LPA observed cleaning supplies and toxins unlocked and accessible to the residents under the bathroom sink in the hallway bathroom.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
	POC Due Date: 06/24/2022
	Plan of Correction
1 2 3 4	During the inspection, staff locked the cabinet under the sink of the hallway bathroom. No furthercorrections required at this time.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

LIC809 (FAS) - (06/04)

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