197610362-4-20-2023-31-AS-NRED-CR3KM9-20230420080111

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610362
Report Date: 04/19/2023
Date Signed: 04/20/2023 08:01:45 AM

Document Has Been Signed on 04/20/2023 08:01 AM - 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:	ANTORIA ASSISTED LIVING OF TARZANA		FACILITY NUMBER:	197610362
ADMINISTRATOR:	CAMPOS, MARYCEL		FACILITY TYPE:	740
ADDRESS:	5912 CAHILL AVENUE		TELEPHONE:	(626) 840-2830
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	6	CENSUS: 6	DATE:	04/19/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Marycel Campos		TIME COMPLETED:	03:55 PM

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At 1:00 p.m. on 04/19/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced prelicensing inspection. LPA met with the licensee and disclosed the reason for the visit. LPA and licensee toured the facility inside and out from 1:00 p.m. to 2:00 p.m. No immediate health and safety concerns were observed.

Today’s prelicensing inspection results from a change of ownership with residents in care. It is a single story building with 7 bedrooms, 4 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents, of which 1 may be bedridden in Bedroom #5 or Bedroom #6. The facility serves residents with dementia.

Upon entry, signs were observed for the facility’s visitation policy, house rules, confidential complaint contacts, Ombudsman contacts, emergency disaster plan, personal rights, rights of resident councils, house rules, and COVID policies. A screening station for infectious disease was observed at the main entrance. Ramps which lead from Bedroom #5 and the rear patio were sturdy and in good condition. Hand rails were also sturdy. LPA observed 8 out of 8 auditory alarms on and functioning. All emergency exit paths were free from obstructions. The rear exit gate was unlocked with an inward facing latch. The facility had 7 bedrooms. 1 bedroom was designated for staff. The staff room was locked and inaccessible to residents in care. All resident bedrooms were single occupancy rooms with a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. The facility had 4 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 1:15 p.m. LPA measured the water temperature in the shared bathroom to be within regulations. The living room contained the house telephone, board games, art supplies, and reading materials. Furniture was in good repair. The fireplace was turned off and appropriately grated. LPA observed a resident eating at the dining room table. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

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: ANTORIA ASSISTED LIVING OF TARZANA	FACILITY NUMBER: 197610362
	VISIT DATE: 04/19/2023

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At 1:20 p.m. LPA measured the room temperature to be 71 degrees Fahrenheit. At 1:22 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 05/16/2022. The medication cabinet was locked and contained resident medications and a fully-stocked first aid kit. LPA observed an adequate supply of perishable and non-perishable food. The stove hood was clean and appliances were functional. A weekly menu was posted on the refrigerator. Sharps were locked under the stove, and cleaning solutions were locked under the sink. The laundry area was located near the kitchen. It contained an operable washer and dryer. Detergent was locked above the appliances. At 1:30 p.m. LPA tested the dual-purpose smoke and carbon monoxide detector in the laundry room to be operational. When tested, 3 out of 3 smoke detectors functioned simultaneously. The outdoor areas in the front and back yard contained 3 shaded seating areas with furniture in good condition. The back yard contained a storage shed with extra equipment.

At 2:45 p.m. LPA and the licensee reviewed Component III. Pre-Licensing is complete and this facility has no deficiencies. Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC809 (FAS) - (06/04)

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