197610186-11-4-2021-31-AS-ADUA-C8G269-20211104170646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610186
Report Date: 11/04/2021
Date Signed: 11/04/2021 05:06:51 PM

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:	SUMMIT ASSISTED LIVING OF TARZANA		FACILITY NUMBER:	197610186
ADMINISTRATOR:	ANDERSON, DANA		FACILITY TYPE:	740
ADDRESS:	5711 RESEDA BLVD.		TELEPHONE:	(415) 710-7538
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	135	CENSUS: 56	DATE:	11/04/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Dana Anderson, ED		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Abeye Duguma conducted an announced Pre-licensing visit at 10:30 AM and met with the Executive Director Dana Anderson. This is a change of ownership application from Brookdale North Tarzana (LIC- 197602414) to Summit Assisted Living of Tarzana (LIC- 197610186). LPA conducted an entrance interview with the Executive Director. At the time of this visit LPA Duguma observed sixteen (16) individuals working in the facility and the roster shows that there are thirty six (36) staff in total. LPA Duguma also observed and assessed six (06) residents in the facility. All residents appear to be clean and groomed. With the assistance of the Administrator, LPA conducted a Facility Tour of both the inside and outside. The facility was inspected for Fire Safety, Personal Accommodations and Services, Medication Procedures and Food Service. This is a three (03) story property. Fire Clearance is approved for eighty five (85) non-ambulatory and fifty (50) bedridden residents. Facility has ninety two (92) bedrooms and ninety two (92) full bathrooms with showers for residents. Ninety (90) of the resident bedrooms are private, two (02) are semiprivate (one is located on the first floor and the other on the third floor). All bathrooms have properly installed grab bars and have non-skid mats/transferable chairs in the showers. Hot water temperature measured at 118.8ºF during the visit. The facility maintains a comfortable temperature of 77ºF. All residents’ bedrooms were adequately furnished. The common areas were appropriately furnished and had adequate furniture. The LPA observed entertainment equipment and games for activities. The resident and staff records were stored in the Business Office near the main entrance. The first-aid kit is complete. The facility has adequate linen, water, perishable and nonperishable food supplies. The clean linens were stored in the residents' rooms in their closets. Facility does not have a fireplace. Smoke and Carbon Monoxide detectors were checked and function properly. There are multiple fully charged fire extinguishers located throughout the facility. All fire extinguishers were last inspected 11/02/2021. LPA Duguma observed a washer and dryer in the laundry room located on the first floor. All chemicals stay locked in the laundry room. All residents purchase and store personal hygiene items in their rooms. LPA inspected the kitchen and observed stove and refrigerator to be clean and working. Facility had sufficient quantity and variety of perishable and nonperishable foods.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

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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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: SUMMIT ASSISTED LIVING OF TARZANA	FACILITY NUMBER: 197610186
	VISIT DATE: 11/04/2021

NARRATIVE

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Nonperishable foods are stored in the chef's office. The medications are located in the Med Tech office on the second floor which is locked at all times. There is enough outdoor space with seating and available shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. At the time of this visit, the physical plant meets all Title 22 requirements. Component III orientation completed. No health and safety hazards were noted during this visit.

Exit interview was conducted and a copy of 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: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC809 (FAS) - (06/04)

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