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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609991
Report Date: 05/06/2023
Date Signed: 05/06/2023 03:46:30 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/08/2023 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20230308084055
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:
05/06/2023
UNANNOUNCEDTIME BEGAN:
08:11 AM
MET WITH:Marycel CamposTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility not following COVID-19 protocols.
Medications are not stored in a locked cabinet.
Knives are accessible to residents.
Facility placed child proof doorknobs on facility doors.
Residents do not have access to the entire facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Marycel Campos and explained the reason for the visit.

---Facility not following COVID-19 protocols.

It was alleged that caregivers are not wearing mask during a visit by other parties. To investigate the allegation, on 03/14/2023 LPA conducted physical plant tour at around 9:30 AM and interviewed staff from 10:30 AM – 11:15 AM. During the physical plant tour, LPA observed that Staff #1 (S1) was not wearing mask upon entry and was walking in and out of residents’ rooms without a mask.

(CONT. on LIC 9099-C)

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 31-AS-20230308084055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/06/2023
NARRATIVE
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During interviews with S1, they admitted that they were not wearing a mask during an inspection visit conducted by other parties.

Based on the information revealed from observations and interviews, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

---Medications are not stored in a locked cabinet.

It was alleged that medication was unlocked in the kitchen. To investigate the allegation, on 03/14/2023 LPA conducted physical plant tour at around 9:30 AM and interviewed staff from 10:30 AM – 11:15 AM. During the physical plant tour, LPA observed Over-the-Counter medications in an unlocked kitchen cabinet accessible to residents. During interviews, Staff #1 (S1) and Staff #2 (S2) both stated that they always keep the medications locked.

Based on the information revealed from observations, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

--- Knives are accessible to residents.

It was alleged that knives were unlocked in the kitchen. To investigate the allegation, on 03/14/2023 LPA conducted physical plant tour at around 9:30 AM and interviewed staff from 10:30 AM – 11:15 AM.

(CONT. on LIC 9099-C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 31-AS-20230308084055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/06/2023
NARRATIVE
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During the physical plant tour, LPA observed sharps and knives in an unlocked kitchen drawer accessible to residents. During interviews, Staff #1 (S1) and Staff #2 (S2) both stated that they keep the sharps and knives locked.

Based on the information revealed from observations, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

---Facility placed child proof doorknobs on facility doors.

It was alleged that facility placed child proof devices on doorknobs to prevent residents from opening doors. To investigate the allegation, on 03/14/2023 LPA conducted physical plant tour at around 9:30 AM and interviewed staff from 10:30 AM – 11:15 AM. During the physical plant tour, LPA observed child proof devices on the living room doorknob leading to the backyard and room #3’s (three) exit doorknob. During interviews with S1, they admitted that they had child proof devices on the doorknobs during a visit by other parties, but that they were all removed.

Based on the information revealed from observations and interviews, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):


(LIC 9099-C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 31-AS-20230308084055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/06/2023
NARRATIVE
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---Residents do not have access to the entire facility.

It was alleged that residents are prevented from accessing their entire home. To investigate the allegation, on 03/14/2023 LPA conducted physical plant tour at around 9:30 AM and interviewed staff from 10:30 AM – 11:15 AM. During the physical plant tour, LPA observed that facility had signs in the kitchen that state, “NO UNAUTHORIZED PERSONNEL BEYOND THIS POINT” and a kitchen door that was closed but not locked with the same sign. During interviews with staff, Staff #1 (S1) stated that the signs are to keep family out of the kitchen and, when there is danger, for the safety of the residents, they tell them to stay out.

Based on the information revealed from observations and interviews, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 31-AS-20230308084055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2023
Section Cited
CCR
87470(c)(1)(F)
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87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by;
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Corrected during the visit. All staff put on their masks as instructed.
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Based on observations and interviews, the licensee did not ensure that staff are wearing mask at all times while at the facility and that all visitors are screened upon entry which poses an immediate health, safety and personal rights risk to residents in care.
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Type B
05/13/2023
Section Cited
CCR
87705(f)(2)
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87705 (f) Care of Persons with Dementia: The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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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 87705 Care of Persons with Dementia; The written letter must be sent to the LPA by the POC due date.
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This requirement is not met as evidenced by: Based on observation and interviews, the licensee failed to ensure that items were inaccessible to residents with dementia, which poses an immediate health and safety 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: 05/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 31-AS-20230308084055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2023
Section Cited
CCR
87705(f)(1)
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87705(f) Care of Persons with Dementia. The following items shall be made inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to resident(s). This requirement is not met as evidenced by:
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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 87705 Care of Persons with Dementia; The written letter must be sent to the LPA by the POC due date.
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Based on observation and interviews, the licensee failed to ensure that items were inaccessible to residents with dementia, which poses an immediate health and safety risk to residents in care.
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Type B
05/06/2023
Section Cited
CCR
87468.1(a)(6)
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87468.1(a)(6) Personal Rights of Residents in All facilities-To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by:
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Corrected during the visit. The devices on the doors were removed during the visit.
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Based on observation LPA observed a device on the back door of the facility and a resident bedroom which stopped residents from opening the door and would stop them from leaving the facility which poses an immediate health and safety risk to all 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: 05/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 31-AS-20230308084055
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2023
Section Cited
CCR
87468.1(a)(3)
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(a) Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or actions of a punitive nature, such as...interfering with daily living functions...This requirement is not met as evidenced by;

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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 87468.1 Personal Rights of Residents in All Facilities; The written letter must be sent to the LPA by the POC due date.
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Based on observations and interviews, residents are being restricted from accessing the kitchen which is a part of their living space and 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: 05/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7