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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609991
Report Date: 05/13/2023
Date Signed: 05/13/2023 03:55:38 PM


Document Has Been Signed on 05/13/2023 03:55 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:TARZANA ASSISTED LIVINGFACILITY NUMBER:
197609991
ADMINISTRATOR:CHILIAN, HRIPSIMEFACILITY TYPE:
740
ADDRESS:5912 CAHILL AVETELEPHONE:
(818) 429-0797
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:6CENSUS: 4DATE:
05/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Arlene Aragon TIME COMPLETED:
04:00 PM
NARRATIVE
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This Case Management report is in conjunction with Complaint Control # 31-AS-20230313103122.

On 03/14/2023, Licensing Program Analyst (LPA) Abeye Duguma conducted a physical plant tour at around 9:30 AM and interviewed staff from 10:30 AM – 11:15 AM. During the physical plant tour, LPA did not find sample menu in facility files. During interviews with staff, Staff #1 (S1) and Staff #2 (S2) stated that they do not have a sample menu on file for residents and prospective residents.

Based on observations and interviews, the facility did not maintain a sample menu in their files for residents and prospective resident to review upon request. Therefore, pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2023
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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Document Has Been Signed on 05/13/2023 03:55 PM - 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: 05/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2023
Section Cited
CCR
87555

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87555 General Food Service Requirements: (b) The following food service requirements shall apply: (6) Facilities licensed for less than sixteen (16) residents shall maintain a sample menu in their file. Menus shall be made available for review by the residents ortheir designated representatives and the
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87555 General Food Service Requirements; The written letter must be sent to the LPA by the POC due date.
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 licensing agency upon request. This requirement is not met as evidenced by;
Based on record review and interview, the facility does not have a menu available for review which poses a potential health, safety, and personal rights risk to residents in care.
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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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2023
LIC809 (FAS) - (06/04)
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