197610186-8-1-2022-31-AS-EMIR-CHDUX2-20220817155733

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610186
Report Date: 08/01/2022
Date Signed: 08/01/2022 04:11:17 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/28/2022 and conducted by Evaluator Yelena Avetisyan

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20220728154832

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:	135	CENSUS: 47	DATE:	08/01/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Jodi Kanowitz		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Due to Lack of Care Resident 1 (R1) Developed pressure injuries.

INVESTIGATION FINDINGS:

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An unannounced initial 10 day complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival LPA met with Armando Rivera designated person in charge. Approximately 10:20am Administrator Jodi Kanowitz arrived to the facility.

Regarding the allegation above it was reported that Resident 1 (R1) was admitted to the hospital with a pressure injury, and rash with open skin. To investigate this allegation at approximately 11:00 am the LPA conducted review of records fro 5 residents and obtained copies of documents pertinent to the allegation. From approximately 2:00pm LPA conducted interview with facility staff, telephone interview with staff from Paramount Home Health Services and Telephone interview with R1's Power of Attorney. Records reviewed and interviews conducted revealed that R1 is independent and did not receive assistance with any Activities of Daily Living prior to hospitalization. Facility staff would not be aware of R1 having any skin condition unless R1 choose to report it to them. Based on the information obtained during the course of the investigation the allegation is Unsubstantiated at this time.

Exit interview conducted and copy of report issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

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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