197610142-6-14-2023-31-AS-EMIR-D9EU9L-20240924152315

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610142
Report Date: 06/14/2023
Date Signed: 06/14/2023 02:31:02 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
06/08/2023 and conducted by Evaluator Mariana Agban

COMPLAINT CONTROL NUMBER: 31-AS-20230608160428

FACILITY NAME:	ATRIA TARZANA		FACILITY NUMBER:	197610142
ADMINISTRATOR:	IRMA ARTEAGA		FACILITY TYPE:	740
ADDRESS:	5325 ETIWANDA AVENUE		TELEPHONE:	(877) 483-6827
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	136	CENSUS: 108	DATE:	06/14/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Erma Arteaga-Executive Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility is not providing all agreed upon services to resident(s)

INVESTIGATION FINDINGS:

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At 10:15am, Licensing Program Analysts (LPAs) Mariana Agban and Angela Panushkina conducted an unannounced complaint visit to investigate the above stated allegation. LPAs met with the Executive Director and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:20am, LPAs met with the Executive Director and requested resident and staff roster. At approximately 10:30am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. At 1:15pm, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s report, Appraisal Needs and Services Plan, Monthly completed Task by Resident, etc., relevant to the investigation. Between 10:40am – 1:10pm, LPAs interviewed the Executive Director, two (2) staff members and nine (9) out of eleven (11) residents.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230608160428

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA TARZANA	FACILITY NUMBER: 197610142
	VISIT DATE: 06/14/2023

NARRATIVE

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It was alleged that the facility is not providing all agreed upon services to resident(s). To investigate this allegation LPAs conducted interview with the Executive Director and were informed that the facility Admission Agreement has optional services and extra level of care rates for the residents. LPAs were informed that prior to or at the time of residents' admission into the Community, level of care and services will be determined during the first 30 days of admission. In addition, interviews with the Executive Director, Community Care Manger and two (2) staff members revealed that facility always follows Admission Agreement and provides extra services for residents upon request. Although, interview with two (2) staff members revealed that they receive a daily schedule that they must follow during their shift, some residents may refuse services for a certain time and request the staff member to come in a later time. Both staff members also informed LPAs that if the task is not complete before their shift is over, the next shift staff member will be notified and a follow up attempt will be conducted. Moreover, interviews with eight (8) out of eleven (11) residents revealed that the facility always follows the Admission Agreement by meeting all residents needs. Lastly, review of monthly completed task records for the months of April, May and June 2023, revealed that R1 is receiving all requested and paid services by the facility. Based on interviews and record review, this allegation deemed UNSUBSTANTIATED

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC9099 (FAS) - (06/04)

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