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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610186
Report Date: 09/13/2022
Date Signed: 09/13/2022 02:14:06 PM

Substantiated


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
09/06/2022 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20220906154027
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: 45DATE:
09/13/2022
UNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Sherene Thomas, Carmelita RoxasTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not seek timely medical care for resident in care
Staff do not ensure the facility is free from pests
Staff did not complete an admission agreement with resident or resident's representative
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Evelin Rios and Michael Cava conducted a complaint visit to the facility to investigate the above allegations. During the course of the investigation, LPAs met and interviewed the Executive Director, Sherene Thomas, and the Health and Wellness Director, Carmelita Roxas. Additional interviews with staff and resident were also held. Also conducted during the visit were record review and a physical plant inspection.

Staff did not seek timely medical care for resident in care:
In regards to the allegation, it was reported that approximately three weeks ago, Resident 1 (R1) had a fall, sustaining injuries to their knee, elbow and right eye. Although first aid was applied to R1's injuries, medical care wasn't offerred, which R1 would have preferred and confirmed this as their preference during their interview the LPAs. Furthermore, R1 stated they had to make an appointment with their primary physician to examine their injuries. Based on the information obtained, the evidence revealed that timely medical care
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
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 6
Control Number 31-AS-20220906154027
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/13/2022
NARRATIVE
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wasn't provided as preferred by R1. Therefore the allegation is Substantiated. Citation issued on the 9099D

Staff do not ensure the facility is free from pests:
In regards to the allegation, it was reported that facility has cockroaches, beetles and mosquitos that were observed on the resident's bed, bathtub and sinks. LPAs conducted interviews with six (6) residents. Three (3) of the six (6) residents confirmed that they have experienced cockroaches and insects in their rooms. During a plant inspection, LPAs also observed cockroaches in resident's bathroom, in between the toilet and sink. Based on interviews and observation during a physical plant inspection, the above allegation is Substantiated. Citation issued on the 9099D.

Staff did not complete an admission agreement with resident or resident's representative:
In regards to the allegation, it was reported that the facility had a change in ownership on or around February 2022, but no new Admission Agreements were issued since the change. Review of the facility license and profile confirm that the facility was issued their license on January 25, 2022 because there was a change in ownership. LPA reviewed six (6) resident admission agreements. Six out of the six agreements were still under the prior license, which was Brookdale. Therefore, based on this review, the allegation is Substantiated. Citation issued on the 9099D.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20220906154027
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2022
Section Cited
CCR
87465(g)
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Incidential Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health. This requirment was not met as evidenced by: approximately three weeks ago, R1 had a fall, sustaining injuries to their knee, elbow
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As POC, licensee will hold staff training to address this section of the regulation. As proof training was held, the licensee will submit an attendance sheet with the training title to the licensing agency by 9/27/22.
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& right eye. Although 1st aid was applied, per interview, R1 would have preferred immediate medical attention. This poses an immediate health and safety risk to the residents in care.
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Type A
09/13/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: During the investigation, 3 out of 6 residents stated they've encountered cockroaches in their rooms. Furthermore, during a physical
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Although the licensee has hired a pest control company to service the facility for insects and rodents, as POC, the licensee will submit a plan to address the issue the facility continuing to have issues with roaches despite service from the pest control company. This plan is due to the
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plant inspection conducted during the complaint investigation, LPAs Rios and Cava observed cockroaches in resident's room. This poses an immediate health and safety risk to the residents in care.
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licensing agency by 9/20/22.
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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20220906154027
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2022
Section Cited
CCR
87507(e)
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Admission Agreements: The licensee shall provide a copy of the signed and dated current admission agreement, and all signed and dated modifications, to the resident immediately upon signing the admission agreement or modification. This requirement was not met as evidenced by: On 1/25/22,
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Licnesee will submit an appeal.
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facility was newly licensed under a change in ownership. LPAs Rios and Cava conducted a review of six (6) resident's admission agreements. All six (6) Admission Agreement was still under the previous licensee, which was Brookdale.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
09/06/2022 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20220906154027

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: 45DATE:
09/13/2022
UNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Sherene Thomas, Carmelita RoxasTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not attend to resident in a timely manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Evelin Rios and Michael Cava conducted a complaint visit to the facility to investigate the above allegations. During the course of the investigation, LPAs met and interviewed the Executive Director, Sherene Thomas, and the Health and Wellness Director, Carmelita Roxas. Additional interviews with staff and resident were also held. Also conducted during the visit were record review and a physical plant inspection.

Staff do not attend to resident in a timely manner:
In regards to the allegation, it was reported that Resident 2 (R2) waits more than 20 minutes for staff to help them go from the dining room to their room. During the course of the investigation, LPAs Rios and Cava interviewed R2, who expressed no complaints or concerns that they have to wait for staff assistance to get from the dining room to their room. R2 stated they have staff wait on them to assist in tranporting them back to their room. In addition, LPAs Rios and Cava interviewed six (6) residents. Four (4) of the six
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20220906154027
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/13/2022
NARRATIVE
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expressed no complaints or concerns with staff not attending to them in a timely manner. Based on the information obtained, there was insufficient evidence to corroborate the allegation. Therefore, the investigation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6