197610366-11-22-2023-31-AS-NMAN-D5KP8F-20240524110529

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610366
Report Date: 11/22/2023
Date Signed: 11/22/2023 03:59:14 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
10/04/2023 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20231004112343

FACILITY NAME:	SUMMIT ASSISTED LIVING OF TARZANA		FACILITY NUMBER:	197610366
ADMINISTRATOR:	DAVID AGUINIGA		FACILITY TYPE:	740
ADDRESS:	5711 RESEDA BLVD		TELEPHONE:	(818) 996-2022
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	176	CENSUS: 53	DATE:	11/22/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Jina Maleksarkissians		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility is in disrepair

INVESTIGATION FINDINGS:

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At 8:30 a.m. on 11/22/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with the administrator and disclosed the reason for the visit. LPA toured the facility at 8:45 a.m. today.

To investigate the allegations listed above, LPA conducted an initial visit at approximately 12:00 p.m. on 10/04/2023 and interviewed the former Executive Director at 12:10 a.m., reviewed records at 1:30 p.m., and toured the facility at approximately 3:45 p.m. LPA called the Long Term Care Ombudsman (LTCO) at 8:40 a.m. on 10/19/2023 for information about their visit to the facility on 10/17/2023. During a subsequent visit at 11:20 a.m. on 10/24/2023, LPA interviewed Resident #1 (R1) at 11:30 a.m., the former Executive Director at 12:30 p.m., and toured the facility at 12:00 p.m. LPA conducted another visit at 8:30 a.m. on 11/01/2023 and interviewed ten percent of residents, or six (06) out of fifty-three (53) residents and five (05) staff members between 8:30 a.m. and 3:00 p.m.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20231004112343

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SUMMIT ASSISTED LIVING OF TARZANA	FACILITY NUMBER: 197610366
	VISIT DATE: 11/22/2023

NARRATIVE

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Regarding the allegation “Facility is in disrepair”, it was alleged the front elevator has made a loud squeaking noise when opening since September 2023. A repair company came to fix the elevator on 10/03/2023, but the problem got worse on 10/17/2023 when the elevator made a loud banging noise upon descending to the first floor. Interview with the former Executive Director at 12:10 a.m. on 10/04/2023 revealed the facility schedules maintenance with Elevator Support Services every month. They last visited on 10/03/2023. Telephone call with the LTCO at 8:40 a.m. on 10/19/2023 revealed that although the maintenance company came on 10/16/2023, the issue was not fixed. Interview with the former Executive Director at approximately 12:30 p.m. on 10/24/2023 confirmed that maintenance was scheduled on 10/16/2023 to apply grease to fix the squeaking noise. Interview with Staff #2 (S2) at 8:45 a.m. on 11/01/2023 and R1 at 11:30 a.m. on 10/24/2023 revealed the elevator repair company came three times in the month of October. Nothing changed after the first visit, and R1 confirmed the loud banging noise occurred after the second visit. R1 stated a third visit by the elevator repair company fixed the problem. Two (02) out of the six (06) residents interviewed between 9:00 a.m. and 3:00 p.m on 11/01/2023 revealed they noticed the loud banging noise, and one (01) out of the six (06) residents noticed the squeaking noise but was okay with it. LPA observed the squeaking noise at approximately 3:45 p.m. on 10/04/2023 but not on 10/24/2023. LPA discussed elevator maintenance with the current Executive Director at 5:00 p.m. on 11/01/2023, and LPA was notified that the problem was fixed by 11/02/2023. Based on interviews and observations, the facility requested maintenance multiple times to fix the elevator issue, and the issue was eventually fixed. Therefore, the allegation is deemed SUBSTANTIATED at this time, and a Technical Violation is issued without deficiency.

No immediate health and safety hazards were noted during this visit.

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

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC9099 (FAS) - (06/04)

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