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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610142
Report Date: 08/10/2021
Date Signed: 08/10/2021 11:37:15 AM

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:ATRIA TARZANAFACILITY NUMBER:
197610142
ADMINISTRATOR:RAFAT, SHAKEBFACILITY TYPE:
740
ADDRESS:5325 ETIWANDA AVENUETELEPHONE:
(877) 483-6827
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:136CENSUS: 109DATE:
08/10/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Shakeb RafatTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director/Administrator Shakeb Rafat for a Pre-Licensing visit. Fire clearance was approved on 03/09/2021, for non-ambulatory and no delayed egress system. There is a hospice waiver for (10), with a capacity of (136). The current census is (109). Upon entry, LPA was COVID screened, with temperature check and responded to a questionnaire. Executive Director informed LPA, there are no positive cases, and 100% of staff and residents are vaccinated. All staff and residents are required to wear face masks in common areas; except residents can leave them off in private rooms, or when eating. There are hand sanitizing stations throughout the facility.

The facility consists of a (4) story building with underground parking. Activity and daily menu were visibly posted, as well as Licensing and COVID signs. There are resident rooms on each floor; and (2) bathrooms: (1) for staff and the other for residents. LPA inspected all areas of the facility: Administration, medication room, game room, fitness center, outdoor patio, library, dining room, kitchen, beauty salon, and resident rooms and bathroom. Each room is provided appliances, such as stove, refrigerator, microwave, washer/dryer, and basic cable services. There are (2) types of signal features used. Facility uses Phillips Life-Line alert pull chords in resident restroom, kitchen and all residents carry a pendant. Caregivers are provided pagers, that identify when an alarm is signaled. The signal is also heard by the receptionist desk computer. Facility has also installed pull chords in the public restrooms. Facility has an emergency generator that will keep lights, phones, elevators, and main food freezers operating during power outages. The main kitchen and dining room are located on the (1st) floor. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: ATRIA TARZANA
FACILITY NUMBER: 197610142
VISIT DATE: 08/10/2021
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Facility has adequate perishable and nonperishable food and water supplies. Medications were kept in the medication room with locked cabinets inaccessible to residents in their rooms. The facility staff's an LVN who handles training of caregivers including medication technicians. There is an in-ground spa that is gated and kept locked and inaccessible to residents. The physical plant inside and outside was free from obstruction, with clear passageways. The facility is currently in compliance with Title 22 regulations.

Exit interview, and copy of report issued to Executive Director.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC809 (FAS) - (06/04)
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