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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610362
Report Date: 05/01/2024
Date Signed: 05/01/2024 04:00:46 PM


Document Has Been Signed on 05/01/2024 04:00 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:ANTORIA ASSISTED LIVING OF TARZANAFACILITY NUMBER:
197610362
ADMINISTRATOR:CAMPOS, MARYCELFACILITY TYPE:
740
ADDRESS:5912 CAHILL AVENUETELEPHONE:
(626) 840-2830
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:6CENSUS: 6DATE:
05/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Eleonor VelascoTIME COMPLETED:
04:05 PM
NARRATIVE
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At 10:45 a.m. on 05/01/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit.

LPA and staff toured the facility inside and out at 10:50 a.m.

The facility was last visited on 04/19/2023 for a prelicensing visit. It is a single story building with seven (07) bedrooms, four (04) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents, of which one (01) may be bedridden in Bedroom #5 or #6. The facility serves residents with dementia. Approved hospice waivers for six (06).

The front yard was well maintained and contained a fountain, a carport, and ramps in good condition leading to the front door. At the main entrance, LPA observed postings for COVID precautions, visitation policy, confidential complaint contacts, Ombudsman contacts, facility license, administrator certificate, house rules, personal rights, rights of resident councils, emergency disaster plan, theft and loss policy, activity schedule, and the lists of staff and residents. A sign was hung stating “No smoking – Oxygen in use”.

At approximately 10:55 a.m. LPA observed a fully charged fire extinguisher in the kitchen. At 11:00 a.m. LPA called the house telephone and confirmed it to be operational. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter top. Medications and confidential files were locked near the dishwasher. A washing machine and dryer were located in a laundry area adjacent to the kitchen. Both were in working order. Detergents and cleaning solutions were locked above the appliances.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANTORIA ASSISTED LIVING OF TARZANA
FACILITY NUMBER: 197610362
VISIT DATE: 05/01/2024
NARRATIVE
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The staff room was locked and located past the laundry room. The facility has six (06) other private bedrooms for residents. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition.

Bathrooms: The facility has four (04) bathrooms. All bathrooms contained liquid soap, 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. Staff stated residents use their personal hand towels to dry their hands. At approximately 11:10 a.m. LPA measured the water temperatures in the bathrooms near the staff room and the bathroom in Bedroom #5 to be 137.0 degrees Fahrenheit and 134.5 degrees Fahrenheit. This deficiency is cited on the LIC 809-D page.

Walls, floors, windows, screens, and blinds were clean and in good repair. A resident was observed watching television in the living room. The living room contained exercise equipment, reading material, an appropriately covered fireplace, and furniture in good repair. A linen closet in the hallway contained an adequate supply of fresh linens. At 11:20 a.m. LPA measured the room temperature to be 71 degrees Fahrenheit.

LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition as well as two rabbits and a dove. Hand rails were secure. The back yard contained a gardened area. All emergency exit paths were free from obstructions. Three (03) out of three (03) exit gates were unlocked with self-closing latches. Evacuation routes were posted. Auditory alarms were turned on and functioning. Fire sprinklers were observed throughout the house. At approximately 11:30 a.m., smoke and carbon monoxide detectors were tested and operational.

LPA conducted a record review of staff and resident files at 11:45 a.m. At approximately 12:45 p.m. LPA observed two (02) out of two (02) staff CPR/First Aid certifications were not present. This deficiency is cited on the LIC 809-D page.

Exit interview conducted. Appeal Rights discussed. Copy of report provided.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/01/2024 04:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: ANTORIA ASSISTED LIVING OF TARZANA
FACILITY NUMBER: 197610362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two (02) resident hot water faucets which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
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Licensee has agreed to remeasure hot water temperatures and request maintenance if necessary by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/01/2024 04:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: ANTORIA ASSISTED LIVING OF TARZANA
FACILITY NUMBER: 197610362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two (02) out of two (02) staff present which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2024
Plan of Correction
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Licensee has agreed to have staff renew their CPR and first aid certifications by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4