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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610366
Report Date: 03/08/2024
Date Signed: 03/08/2024 03:39:02 PM


Document Has Been Signed on 03/08/2024 03:39 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:SAVANT OF TARZANAFACILITY NUMBER:
197610366
ADMINISTRATOR:RITA MELDONIANFACILITY TYPE:
740
ADDRESS:5711 RESEDA BLVDTELEPHONE:
(818) 996-2022
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:176CENSUS: 59DATE:
03/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Rita MeldonianTIME COMPLETED:
03:45 PM
NARRATIVE
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At 8:30 a.m. on 03/08/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and later the administrator and disclosed the reason for the visit. LPA was joined by Long Term Care Ombudsman (LTCO) Diane Torres at 9:00 a.m.

Today’s case management visit was conducted after the administrator submitted a report stating Resident #1 (R1) left the facility unsupervised at approximately 5:00 a.m. on 02/25/2024. The facility reported the incident properly to all appropriate parties and followed the plan of operations for missing residents. The administrator explained the details of the incident to LPA during a phone call at approximately 9:00 a.m. on 02/26/2024. The administrator also revealed that R1’s most recent medical assessment stated R1 was not able to leave the facility unsupervised. The administrator stated Staff #1 (S1) and Staff #2 (S2) searched for R1 but could not find them. R1 was eventually found at the Veteran’s Affairs (VA) office in Long Beach. Due to the absence of supervision of R1, the facility is cited a deficiency on the attached LIC 809-D page and issued an immediate civil penalty of $500 pursuant to California Code of Regulations 87646(d).

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: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
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 2


Document Has Been Signed on 03/08/2024 03:39 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: SAVANT OF TARZANA
FACILITY NUMBER: 197610366

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/15/2024
Section Cited
CCR
87464(d)

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87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs
This requirement is not met as evidenced by:
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Licensee has agreed to review all current and future resident LIC 602s and update resident care plans to meet supervision needs. Licensee to provide a written statement confirming the update by POC due date.
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Based on interviews and record review, the licensee did not comply with the section cited above in one (01) out of sixty (60) residents which poses an immediate Health, Safety, or Personal Rights risk to residents in care.
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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: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2