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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610186
Report Date: 10/26/2022
Date Signed: 10/26/2022 10:18:16 AM

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: 42DATE:
10/26/2022
UNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Sherene ThomasTIME COMPLETED:
10:15 AM
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 Analyst (LPA) Michael Cava comducted a subsequent visit to the facility to issue a Plan of Correction (POC) regarding the above allegations (see LIC 9099 dated 09/13/2022). The complaint was Substantiated, Licensee stated they would appeal the citations, but no POC was issued on that date. Today's visit consists of issuing the POC to address the citations issued on 09/13/2022. LPA met with the administrator, Sherene Thomas, and discussed the POC.

See 9099D citations and POC. A copy of this report given.
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: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
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 2
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: 10/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2022
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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Licensee submitted an appeal 0n 09/28/22. Since last visit, the licensee had already initiated the updated Admission Agreement to each residents. No further corrections needed. Appeal under review by LPM.
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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: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2