197610186-11-22-2023-31-AS-NMAN-D29V6X-20240208151015

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610186
Report Date: 11/22/2023
Date Signed: 11/22/2023 03:57:32 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
04/04/2023 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20230404083253

FACILITY NAME:	SUMMIT ASSISTED LIVING OF TARZANA		FACILITY NUMBER:	197610186
ADMINISTRATOR:	JODI KANOWITZ		FACILITY TYPE:	740
ADDRESS:	5711 RESEDA BLVD		TELEPHONE:	(415) 710-7538
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	0	CENSUS: 53	DATE:	11/22/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Jina Maleksarkissians		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility in disrepair

INVESTIGATION FINDINGS:

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At 8:30 a.m. on 11/22/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and disclosed the reason for the visit. LPA toured the facility inside and out at 8:45 a.m. today.

Regarding the allegation “Facility in disrepair”, it was alleged the facility did not adequately fix the leaky faucet in the room of Resident #1 (R1). R1 submitted several work orders to repair the leak, and the facility maintenance man repaired the leak, but the leak reoccurred.

To investigate the allegation, LPA conducted an initial visit at 2:30 p.m. on 04/13/2023 and interviewed staff #1 (S1) at 2:45 p.m. on 04/13/2023. LPA conducted a subsequent visit on 11/01/2023 and interviewed five (05) staff members and at least 10% (6 out of 53) residents between 8:45 a.m. and 3:00 p.m., inspected R1’s room at 9:00 a.m., and reviewed maintenance records at 3:30 p.m.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

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-20230404083253

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUMMIT ASSISTED LIVING OF TARZANA	FACILITY NUMBER: 197610186
	VISIT DATE: 11/22/2023

NARRATIVE

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Interview with S1 at 2:45 p.m. on 04/13/2023 revealed there were a few leaks in the facility which had been repaired. Interviews with residents between 9:00 a.m. and 2:30 p.m. revealed six (06) out of six (06) residents experienced no leaks or other facility maintenance issues which were not resolved. Record review of the facility maintenance log at 3:30 p.m. on 11/01/2023 did not reveal pertinent information. The maintenance log did not date back to the time of the occurrence. LPA did not observe any leaks today at -:-- or at 9:00 a.m. on 11/01/2023 in R1’s room. Based on interviews, record review, and observations, there is not enough information to verify the allegation is true. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health and safety hazards were noted during this visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC9099 (FAS) - (06/04)

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