197610366-3-21-2023-31-AS-NRED-CQ5QZQ-20230321123708

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610366
Report Date: 03/21/2023
Date Signed: 03/21/2023 12:37:25 PM

Document Has Been Signed on 03/21/2023 12:37 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SUMMIT ASSISTED LIVING OF TARZANA		FACILITY NUMBER:	197610366
ADMINISTRATOR:	THOMAS, SHERINE		FACILITY TYPE:	740
ADDRESS:	5711 RESEDA BLVD		TELEPHONE:	(818) 996-2022
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	176	CENSUS: 36	DATE:	03/21/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Sherene Thomas		TIME COMPLETED:	12:40 PM

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

At approximately 10:00 a.m. on 03/21/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced prelicensing visit. LPA met with the Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out from 10:15 a.m. to 11:30 a.m. No immediate health or safety concerns were observed.

The facility is a three story building with activity rooms, business offices, lounge areas, kitchen, laundry room, three dining rooms and an outdoor area. It has an approved fire clearance for 126 nonambulatory residents, of which 50 may be bedridden.

Upon entry, LPA observed a reception area with a visitor and resident sign-in sheet. An activity room was located near the main entrance. Residents were observed exercising with staff assistance. Business offices were also located near the main entrance. The facility had single and double occupancy rooms on all three floors. Elevators and stairwells were in good condition and free of hazards. Emergency evacuation chairs were observed at the tops of each stairwell. Fire sprinklers were observed in resident rooms and throughout the facility.

LPA and Administrator toured Room #111 on the first floor and Room #221 on the second floor. The bedrooms were in good condition and each contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. The bathrooms contained soap, paper towels, grab bars near the toilet and shower, and non-skid strips in the shower At 10:20 a.m. LPA tested the pull cord system in Room #111 to be operational. The pull cord alerted staff pagers, and staff responded promptly. At 10:24 a.m. and 10:43 a.m. LPA measured the hot water temperatures in the rooms to be 109 degrees Fahrenheit and 117 degrees Fahrenheit, respectively. At 10:26 a.m. LPA tested the smoke detector in Room #111 to be operational.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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 2

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: SUMMIT ASSISTED LIVING OF TARZANA	FACILITY NUMBER: 197610366
	VISIT DATE: 03/21/2023

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

Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 10:37 a.m. LPA measured the room temperature to be 73 degrees Fahrenheit. Additional facility postings included confidential complaint contacts, Ombudsman contacts, emergency contacts, theft and loss policy, personal rights, rights of resident councils, rights of family councils, non-discrimination notice, and emergency disaster plan. Facility sketches were also posted in common areas and near elevators. Resident mailboxes were locked and located near the main entrance. Activity spaces on the first and second floors contained books, puzzles, and refreshments. Daily and monthly activity calendars were posted in the elevator and near the dining rooms. At 10:35 a.m. LPA tested the carbon monoxide detector to be operational. At approximately 10:40 a.m. LPA observed fire extinguishers in the hallways of all three floors. The extinguishers were fully charged and last inspected on 04/26/2022. Chemical solutions and disinfectants were locked and inaccessible on all floors. Residents using oxygen had appropriate signs posted on their doors. The medication room on the second floor contained a fully-stocked first aid kit, medication logs, locked medication carts, and a locked medication refrigerator.

The facility had three separate dining areas which were all appropriately furnished and sanitary. A weekly menu was posted at the dining rooms. Resident refreshments and water were offered nearby as well. The kitchen was near the dining rooms. LPA observed an adequate supply of perishable and non-perishable foods. At approximately 10:51 a.m. LPA measured the refrigerator and freezer temperatures to be 39 and 0 degrees Fahrenheit, respectively. The facility maintained temperature logs. The dishwashing area and chemical cleaners were separate from food storage and preparation areas. Floors and surfaces were clean. Food was stored appropriately.

The laundry room contained 4 operational machines. Staff was observed operating the machines. Detergents were inaccessible to residents. The facility maintained logs for resident laundry.

All emergency exit paths were free from obstructions. Exit gates were unlocked. The outdoor area contained a grill, gardened areas, and covered patio furniture.

During today's inspection, the facility is in compliance with Title 22 regulations. Prelicensing is complete and this facility has no deficiencies.

Licensee, Administrators and LPA reviewed Component III at approximately 11:30 a.m.

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: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2