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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610142
Report Date: 08/30/2022
Date Signed: 08/30/2022 02:52:34 PM


Document Has Been Signed on 08/30/2022 02:52 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:ATRIA TARZANAFACILITY NUMBER:
197610142
ADMINISTRATOR:RAFAT, SHAKEBFACILITY TYPE:
740
ADDRESS:5325 ETIWANDA AVENUETELEPHONE:
(877) 483-6827
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:136CENSUS: 104DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Terry Avakyan, Lucia GarciaTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted an Annual Required visit and inspection of the facility. LPAs met with Terry Avakyan (Community Business Director-CBD) and Lucia Garcia (Community Care Director-CCD). They were advised of the reason for the visit.

At 8:30am, with the assistance of both the CBD and CCD, LPAs took a tour of the physical plant. The smoke alarms are hardwired and interconnected with carbon monoxide detectors that functions properly. There are fire extinguisher located throughout the facility halls. The charge date is .

Kitchen: The kitchen appliances and fixtures were functional. LPAs found a sufficient amount of perishable and non-perishable food at the facility; properly stored. A copy of the daily menu obtained for review.

Resident Rooms: The facility is a four story building. The LPAs inspected three (3) rooms on each floor. Twelve (12) rooms total. Each rooms were properly furnished with appropriate beddings and linens with sufficient lighting. Rooms were observed clean and sanitary. Exits from each rooms were clear of obstruction.

Bathrooms: The resident rooms had it's own private bathroom designated for residents' use. All the bathrooms were properly supplied and had functional fixtures. Hot water temperature taken in resident bathrooms had a range of 108.8 to 118.5 degrees Fahrenheit.

Common Areas: The common areas inspected include the living room, dining area, formal dining room, activity room, den and gym. The common areas were properly furnished. The furniture and gym equipment were observed to be in good repair. The last fire safety inspection, conducted by the State Fire Marshall was made in August of 2021. Smoke alarms, sprinklers, doors, and elevators were tested and included on the report. No defects noted. Next scheduled testing due August 2022. Copy of this report obtained.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
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: 08/30/2022
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The facility held their fire drill on August 23, 2022. No issues identified during the drill that require attention.

Surrounding Grounds: Entry/exits were free of obstruction. The laundry area is located adjacent to the kitchen. There are furniture appropriate for outdoor use. There is a small jacuzzi located outside of the facility which has at least a five foot fence around it's parameters, with the gate observed to be locked. The outdoor area was free of hazards and obstruction.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2