197609991-5-13-2023-31-AS-NMAN-CSYQSC-20230620122521

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609991
Report Date: 05/13/2023
Date Signed: 05/13/2023 03:54:06 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
03/13/2023 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20230313103122

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: 4	DATE:	05/13/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Arlene Aragon		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident's plumbing is in disrepair

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 caregiver Arlene Aragon and explained the reason for the visit. The administrator, Marycel Campos, designated Arlene Aragon as the responsible person to sign and accept this report.

---Resident's plumbing is in disrepair
It was alleged that the facility is having problems with water temperature. 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 tested the hot water which measured at 141.6 degrees Fahrenheit. During interviews with Staff #1 (S1), they stated that they do not periodically check water temperatures, that they only check water temperatures with their hand and that residents have not complained about water temperatures.
(CONT. LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 31-AS-20230313103122

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: 05/13/2023

NARRATIVE

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When Staff #2 (S2) was asked if the facility periodically checks the temperature of the water, they replied, “No”.

Based on the observations and interviews, there is enough information to verify the allegation. Therefore, 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):

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
03/13/2023 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20230313103122

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: 4	DATE:	05/13/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Arlene Aragon		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility telephone is in disrepair.
Staff do not answer the facility telephone.
Staff are not posting a menu for residents.

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 caregiver Arlene Aragon and explained the reason for the visit. The administrator, Marycel Campos, designated Arlene Aragon as the responsible person to sign and accept this report.

---Facility telephone is in disrepair
It was alleged that facility phone makes a nose when trying to reach the front desk. To investigate the allegation, on 03/14/2023 LPA conducted physical plant tour at around 9:30 AM, interviewed staff from 10:30 AM – 11:15 AM and interviewed residents between 11:45 AM to 12:45 PM. During the physical plant tour LPA observed the telephone to be in working condition. LPA also contacted that facility out of view, the ringtone was typical, and Staff #1 (S2) answered the phone. During interviews with the staff, both S1 and Staff #2 stated that the phone is in working order.
(CONT. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 31-AS-20230313103122

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: 05/13/2023

NARRATIVE

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During interviews with residents, Resident #1 (R1) stated that the phone makes a strange noise. All other residents stated that they do not know of any issue with the telephone.

Based on information revealed during observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time.

---Staff do not answer the facility telephone

It was alleged that the facility does not answer the phone at night. To investigate the allegation, on 03/14/2023 LPA interviewed staff from 10:30 AM – 11:15 AM and interviewed residents between 11:45 AM to 12:45 PM. During interviews with the staff, both S1 and Staff #2 stated that they always answer the phone when it rings, even at night. During interviews with residents, Resident #1 (R1) stated that staff do not answer the phone at night. All other residents stated that they have not had any issues with staff not answering the phone.

Based on information revealed during observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time.

---Staff are not posting a menu for residents

It was alleged that there are no menus for residents to expect what their meal will be. 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 does not post any daily, weekly, or monthly menu for residents. During interviews with staff, both S1 and Staff #2 stated that they do not post the meals for residents periodically.

Based on information revealed during observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is unsubstantiated at this time.
Facilities licensed for less than sixteen (16) residents are not expected to post their menus periodically; however, they are expected to keep a menu for residents and their responsible parties to review upon request. During the physical plant tour, LPA requested to see the sample menu, but Staff #1 (S1) and Staff #2 (S2) were not able to provide one. This deficiency will be cited on a separate LIC 809 Case Management report.
Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 31-AS-20230313103122

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: 05/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/20/2023 Section Cited CCR 87303(e)(2)	1 2 3 4 5 6 7	87303 Maintenance and Operation (e)(2) Faucets used by residents for personal care..... the temperature of hot water used by residents to attain a temperature of not less than 105-degree F (41 degree C) and not more than 120-degree F (49 degree C). The requirement is not met as evidenced by:	1 2 3 4 5 6 7	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 87303 Maintenance and Operation; The written letter must be sent to the LPA by the POC due date.
	8 9 10 11 12 13 14	Based on LPAs observation, the hot water temperature was measured beyond the required 105-120 degrees F which poses an immediate Health and Safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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