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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610186
Report Date: 11/16/2022
Date Signed: 11/16/2022 02:56:44 PM


Document Has Been Signed on 11/16/2022 02:56 PM - It Cannot Be Edited

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 TARZANAFACILITY NUMBER:
197610186
ADMINISTRATOR:JODI KANOWITZFACILITY TYPE:
740
ADDRESS:5711 RESEDA BLVDTELEPHONE:
(415) 710-7538
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:135CENSUS: 39DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Shareene Thomas, Carmelita RoxasTIME COMPLETED:
03:15 PM
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In conjunction with a complaint investigation (complaint control #31-AS-20221110141738), Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Shareene Thomas, and Health and Wellness Director (HWD) Carmelita Roxas, and advised them of the Annual.

At approximately 9:13am, with the assistance of the HWD, LPA took a tour of the physical plant. Required postings were posted. The smoke alarms and sprinkler systems were observed and interconnected. The facility is a three story building. There are fire extinguishers located in the hallways on all three floors. The charge date is 1/26/2022.

Kitchen: The facility has an industrial kitchen. The appliances and fixtures were functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored.

Bedrooms: LPA inspected rooms 115, 117, 120 on the first floor, rooms 233 and 237 on the second floor, and 301 on the third floor. LPA observed the resident rooms to be properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: On the bedrooms mentioned above, the LPA took a water temperature from the bathroom sink in each room. The water temperature measured between 110 to 120 degrees from the bathrooms on all three floors. LPA observed the bathrooms to be properly supplied and had functional fixtures. No cleaning supplies were observed accessible to the residents in care.

Common Areas: These included the living room and dining area. The common areas were properly furnished. The lobby and entrance area was clean, clear and free of any obstruction.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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: 11/16/2022
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Surrounding Grounds: Entry and exits were free of obstruction. There is a center courtyard area that was also free and clear of any obstruction. The laundry area is located on the second floor.

Medications: Centrally stored medications are maintained on the second floor. Several pharmacies are being utilized for resident use. Refills are either done automatically every 30 days, or ordered by the medtech in advance electronically. One resident requires insulin, which they are able to administer with the assistance of their home health nurse. The nurse disposes of the needle. Timed medication was observed to be locked and inaccessible to unauthorized staff. Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted. A Copy of the Report Issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2