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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610142
Report Date: 04/16/2021
Date Signed: 04/16/2021 03:55:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:ATRIA TARZANAFACILITY NUMBER:
197610142
ADMINISTRATOR:RAFAT, SHAKEBFACILITY TYPE:
740
ADDRESS:5325 ETIWANDA AVENUETELEPHONE:
(877) 483-6827
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:136CENSUS: DATE:
04/16/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Rafat, ShakebTIME COMPLETED:
03:50 PM
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Facility Type: Elderly
Application Type: CHOW
Capacity: 136
Census (if any clients in care): 30

Administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the administrator was verified by correctly answering identity verification question. During COMP II, administrator confirmed the understanding of Title 22. Component II was successfully completed. Administrator has been advised to transmit signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Nicole RouseTELEPHONE: (916) 657-2600
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
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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