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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610186
Report Date: 11/22/2023
Date Signed: 11/22/2023 03:56:37 PM

Substantiated


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-20230404104638
FACILITY NAME:SUMMIT ASSISTED LIVING OF TARZANAFACILITY NUMBER:
197610186
ADMINISTRATOR:JODI KANOWITZFACILITY TYPE:
740
ADDRESS:5711 RESEDA BLVDTELEPHONE:
(415) 710-7538
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:0CENSUS: 53DATE:
11/22/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jina MaleksarkissiansTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not respond to call bells in a timely manner.
Facility has vermin.
INVESTIGATION FINDINGS:
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At 8:30 a.m. on 11/22/23, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with the administrator and disclosed the reason for the visit. LPA toured the facility at 8:45 a.m.

To investigate the allegations listed above, LPA conducted an initial visit at approximately 2:00 p.m. on 04/13/23 and toured the facility at 2:30 p.m., interviewed Staff #1 (S1) at 2:45 p.m., and reviewed pertinent records at 3:00 p.m. During a subsequent visit at approximately 12:00 p.m. on 10/04/23, LPA interviewed Resident #1 (R1) at 4:00 p.m. LPA conducted another visit at 8:30 a.m. on 11/01/23 and interviewed ten percent of residents, or six (06) out of fifty-three (53) residents and five (05) staff members between 8:45 a.m. and 3:00 p.m.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (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)
Page: 1 of 5
Control Number 31-AS-20230404104638
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights...
(a) ...residents... shall have... (4) ... care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency. This requirement was not met as evidenced by:
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Licensee will schedule an in-service training to address the cited section. Proof of correction due by POC due date.
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Based on interviews, the licensee did not comply with the section cited above which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
12/01/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents. This requirement was not met as evidenced by:
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Licensee has ensured continuous pest control services on a monthly and as needed basis. Deficiency is cleared.
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Based on interviews, the licensee did not comply with the section cited above
which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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-20230404104638

FACILITY NAME:SUMMIT ASSISTED LIVING OF TARZANAFACILITY NUMBER:
197610186
ADMINISTRATOR:JODI KANOWITZFACILITY TYPE:
740
ADDRESS:5711 RESEDA BLVDTELEPHONE:
(415) 710-7538
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:0CENSUS: 53DATE:
11/22/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jina MaleksarkissiansTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility not provided activities for residents.
Residents personal belongings are being taken by staff.
INVESTIGATION FINDINGS:
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2
3
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5
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7
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9
10
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12
13
At 8:30 a.m. on 11/22/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with the administrator and disclosed the reason for the visit. LPA toured the facility at 8:45 a.m. today.

To investigate the allegations listed above, LPA conducted an initial visit at approximately 2:00 p.m. on 04/13/23 and toured the facility at 2:30 p.m., interviewed Staff #1 (S1) at 2:45 p.m., and reviewed pertinent records at 3:00 p.m. During a subsequent visit at approximately 12:00 p.m. on 10/04/23, LPA interviewed Resident #1 (R1) at 4:00 p.m. LPA conducted another visit at 8:30 a.m. on 11/01/23 and interviewed ten percent of residents, or six (06) out of fifty-three (53) residents and five (05) staff members between 8:45 a.m. and 3:00 p.m.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (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)
Page: 4 of 5
Control Number 31-AS-20230404104638
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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Regarding the allegation “Facility not provided activities for residents“, it was alleged the facility had not provided activities or residents since August of 2022. LPA interviewed Resident #2 (R2) at 10:20 a.m. on 11/01/23 and Resident #3 (R3) at 2:15 p.m. on 11/01/23. Interviews with R1, R2, and R3 revealed the facility did provide activities in 2022 and 2023. Interview with Staff #4 (S4) at 8:45 a.m. on 11/01/23 revealed that one of the previous Activity Directors had resigned. Interview with Staff #2 (S2) at 11:30 a.m. on 11/01/23 confirmed that the Activity Director left in December of 2022, but the position was filled with no lapse in activities for residents. Interviews with S1 at 2:45 p.m. on 04/13/23 and Staff #3 (S3) at 3:00 p.m. on 11/01/2023 revealed the facility had provided activities for residents during 2022 and 2023. During the initial visit at 2:30 p.m. on 04/13/23, LPA observed an activity calendar posted at the main entrance. Based on interviews and observations, the facility adequately provided activities to residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Residents personal belongings are being taken by staff“, it was alleged staff had taken a resident’s protective pads. Interview with S1 revealed family and outside agencies provide incontinence supplies for residents. If a resident runs out, the family and/or agency are notified, but the facility also has an emergency supply. S1 confirmed staff do not steal and have not stolen supplies from residents. S2 stated they had not taken resident supplies or heard of med techs taking resident supplies. S3 confirmed caregivers do not take supplies of residents and instead report to their supervisor when supplies are needed. Based on interviews, facility staff did not take resident belongings. 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 MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (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)
Page: 5 of 5
Control Number 31-AS-20230404104638
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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Regarding the allegation “Staff do not respond to call bells in a timely manner“, it was alleged the facility took too long to respond to resident call bells. Interview with S1 at 2:45 p.m. on 04/13/23 revealed residents call for assistance on pendants. When a pendant is pushed, caregiver pagers and the front desk are alerted. Interview with R1 at 4:00 p.m. on 10/04/23 revealed R1 has heard caregiver pagers going off at the front desk for nearly twenty minutes. Resident #2 (R2) interviewed at 10:20 a.m. on 11/01/23 stated staff have not always come quickly. Resident #3 (R3) interviewed at 2:15 p.m. on 11/01/23, stated staff took a long time to respond to call buttons. Interview with Staff #2 (S2) at 11:30 a.m. on 11/01/23 revealed care givers respond as quick as they can, but due to short staffing, may take some time if caregivers and med techs are busy. Staff #3 (S3) interviewed at 3:00 p.m. on 11/01/2023 stated if they were showering a resident, or if another caregiver was on break, there had often been only two caregivers per shift to tend to residents, and call button response times were delayed. Based on interviews, the facility did not respond to call button times in a timely manner. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency cited on the attached LIC 809-D page.

Regarding the allegation “Facility has vermin“, it was alleged cockroaches were seen throughout the facility. This allegation was investigated and substantiated on 09/13/22 as part of complaint # 31-AS-20220906154027. The licensee submitted a Plan of Correction in which pest control services would increase. An invoice was submitted from the pest control company indicating an increase in routine services. Interview with R1 revealed they have seen roaches at various times over the past several years. Interview with R2 revealed they had roaches in their room due to spilling their dog food. Interview with R3 revealed pest control came about 6 months ago, and they had not seen any roaches since then. Interview with Staff #4 (S4) at 8:45 a.m. on 11/01/23 revealed the licensee had not paid for pest control services some time between July 2022 and November 2022, and Orkin refused services. S2 confirmed “there were a lot” of roaches since residents left food in their rooms and did not clean. S2 stated Orkin did not service the facility in January and February of 2023. S3 confirmed that they had seen a lot of roaches in January and February of 2023. Based on interviews, the facility did not maintain pest control services and was not free of vermin. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the attached LIC 809-D page.

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 MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (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)
Page: 3 of 5