197610186-11-15-2022-31-AS-MVAO-CM4STE-20221214130924

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610186
Report Date: 11/15/2022
Date Signed: 11/15/2022 02:47:05 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
11/09/2022 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20221109172002

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: 39	DATE:	11/15/2022
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Sharene Thomas, Carmelita Roxas		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not ensure resident was properly clothed.
Facility is unsanitary.
Resident was left soiled for a long period of time.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with the administrator, Sharene Thomas and Health Wellness Director (HWD), Carmelita Roxas, and explained to them the allegations made. At approximately 9:30am-12:00pm, interviews held with the administrator, HWD, and residents. At approximately 12:00pm-1:00pm, a physical plant inspection was made. At approximately 1:00pm to 2:00pm, records were reviewed.

Staff did not ensure resident was properly clothed/Resident was left soiled for a long period of time:
In regards to the allegations, it was reported that on or around 11/8/22, when Resident 1 (R1) was picked up to be taken to the hospital, R1 was observed naked, in critical condition, and completely covered in what appeared to be days worth of his own urine and feces. Interviews with the administrator and the HWD deny the allegations. HWD stated that she was on duty that day, and placed the call to the paramedics because R1 was experiencing some weakness and low blood sugar. HWD stated R1 was not soiled at the time

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

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-20221109172002

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: 11/15/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

of the paramedics pick up. R1 requires a catheter, but is capable of their own catheter care. HWD stated R1 may not had a shirt on at the time the paramedics came to pick up, but R1 wasn't fully naked. R1 has a skin condition, that gets irritated with clothing and prefers not to wear a shirt at times. Interviews with R1 and Resident 2 (R2) also do not corroborate the allegations. Both R1 and R2 had no complaints about staff not being able to meet their needs. R1 recalls what happened on or around 11/8/22. R1 stated they were feeling lethargic and groggy, so paramedics were called to bring them to the hospital. R1 admitted to not having a shirt on when paramedics arrived to pick them up because their skin was feeling irritated, but was not fully naked. R1 also stated that they weren't soiled at the time of paramedics pick up. R1 adds that they use a catheter, but is able to conduct their own catheter care. Based on the information obtained, the allegations of staff not insuring that the resident was properly clothed and that resident was left soiled is deemed Unsubstantiated at this time.

Facility is unsanitary:
In regards to the allegation, it was reported that the resident's living quarters were unsanitary with urine and feces soaked into walls, furniture, and floors. During the investigation, LPA did not observe R1 and R2's room to be unsanitary with urine and feces into walls, furniture and floors. A physical plant inspection was made, and the LPA did not observe any traces or smell of feces or urine during the of resident rooms and common areas. Resident interviews were conducted and it revealed that housekeeping is done once a week. Based on the information obtained, there was insufficient evidence to corroborate the allegation of facility being unsanitary. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2