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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610366
Report Date: 05/15/2024
Date Signed: 05/15/2024 04:27:35 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
09/28/2023 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20230928152014
FACILITY NAME:SUMMIT ASSISTED LIVING OF TARZANAFACILITY NUMBER:
197610366
ADMINISTRATOR:DAVID AGUINIGAFACILITY TYPE:
740
ADDRESS:5711 RESEDA BLVDTELEPHONE:
(818) 996-2022
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:176CENSUS: 74DATE:
05/15/2024
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Rita MeldonianTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not prevent resident from hitting other residents
INVESTIGATION FINDINGS:
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At 4:00 p.m. on 05/15/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with the current Executive Director (ED) and disclosed the reason for the visit.

To investigate the allegation above, LPA conducted an initial visit on 10/04/2023 and interviewed the former ED at 12:10 p.m., Staff #1 (S1) at 3:20 p.m., and reviewed pertinent records at 1:30 p.m. LPA interviewed Resident #1 (R1) at 11:30 a.m. on 10/24/23 during a subsequent visit. During another subsequent visit on 11/01/23, LPA interviewed six (06) out of fifty-three (53) residents, which was 10% of residents, and five (05) staff members between 8:30 a.m. and 3:00 p.m. Today, LPA toured the facility at 4:00 p.m. and interviewed the current ED at 4:15 p.m.

Regarding the allegation “Staff did not prevent resident from hitting other residents” it was alleged Resident #2 (R2) hits residents and staff around the facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 31-AS-20230928152014
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: 05/15/2024
NARRATIVE
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Interview with the former ED revealed it was reported that R2 bumped into R1, but the former ED never witnessed it. The former ED stated the facility was aware of R2’s aggressive behavior. The former ED spoke to R2 about the behavior and sent emails to staff to “keep an eye on" R2, but R2’s plan of care was not updated. Record review of R2’s physician’s report revealed R2 had aggressive behaviors and a diagnosis of dementia. Interview with S1 revealed R2 hit S1 with their walker when they got upset. S1 confirmed that the former ED sent staff an email on how to address the behavior, but staff did not receive a formal training. Interview with R2 at 10:20 a.m. on 11/01/2024 revealed they had never hit anyone. Interview with Staff #2 (S2) at 10:45 a.m. on 11/01/23 revealed they witnessed R2 hit S1. Interview with Staff #3 (S3) at 3:15 p.m. on 11/01/23 revealed they had been hit by R2 as well, and the former ED did nothing about it. Interview with the current ED revealed the facility updated R2’s plan of care i January of 2024 and trained staff at the same time. Based on interviews and record review, the facility did not prevent R2 from hitting others. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the attached LIC 9099-D page and cleared due to prior corrective action.

No immediate health and safety risks were observed.

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: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20230928152014
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
05/15/2024
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
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As of 01/2024, the licensee updated the resident's care plan and trained staff to manage the resident's aggressive behavior. Deficiency cleared.
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Based on interviews, the licensee did not comply with the section cited above in one (01) out of fifty-three (53) residents which posed a potential 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: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/28/2023 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20230928152014

FACILITY NAME:SUMMIT ASSISTED LIVING OF TARZANAFACILITY NUMBER:
197610366
ADMINISTRATOR:DAVID AGUINIGAFACILITY TYPE:
740
ADDRESS:5711 RESEDA BLVDTELEPHONE:
(818) 996-2022
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:176CENSUS: DATE:
05/15/2024
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Rita MeldonianTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Staff are mismanaging resident's finances
Staff did not prevent resident from engaging in inappropriate behaviors
Staff are not meeting resident's medical needs
INVESTIGATION FINDINGS:
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At 4:00 p.m. on 05/15/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with the Executive Director (ED) and disclosed the reason for the visit.

To investigate the allegation above, LPA conducted an initial visit on 10/04/2023 and interviewed the former ED at 12:10 p.m., Staff #1 (S1) at 3:20 p.m., and reviewed pertinent records at 1:30 p.m. LPA interviewed Resident #1 (R1) at 11:30 a.m. on 10/24/23 during a subsequent visit. During another subsequent visit on 11/01/23, LPA interviewed six (06) out of fifty-three (53) residents, which was 10% of residents, and five (05) staff members between 8:30 a.m. and 3:00 p.m. Today, LPA toured the facility at 3:45 p.m. and interviewed the current ED at 4:00 p.m.

Regarding the allegation “Staff are mismanaging resident's finances” it was alleged the facility withheld over $1,000 belonging to R1 in an inaccessible account.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20230928152014
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: 05/15/2024
NARRATIVE
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Interview with the former ED revealed R1’s money was voluntarily placed in a trust account known as Resident Fund Management Service (RFMS).Interview with Staff #2 (S2) at 10:45 a.m. on 11/01/23 revealed residents can access their funds by making a request. After the request, the funds get disbursed in the form of cash a day later. S2 stated they explained this process to R1 while enrolling. S2 stated R1 eventually received their money but R1 did not agree on the amount received. Interview with R1 confirmed they received funds from the account but did not agree that the amount received was correct. Record review at 11:00 a.m. on 11/01/2023 revealed the facility provided all available funds to R1 after rent was paid. Based on interviews and record review, the facility did not mismanage resident funds. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff did not prevent resident from engaging in inappropriate behaviors” it was alleged Resident #2 (R2) stalked Resident #3 (R3). Interview with R2 at 10:20 a.m. on 11/01/23 revealed they never stalked anyone. Interview with R3 at 12:40 p.m. on 11/01/23 revealed they were not stalked by anyone. Interviews with five (05) out of five (05) staff and four (04) other residents on 11/01/23 revealed they had no knowledge or reports of residents stalking or being stalked. Based on interviews, no residents were stalking or being stalked. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff are not meeting resident's medical needs” it was alleged R1 had cellulitis on both feet and a scratch on their leg which was not properly cared for. Interview with the former ED revealed the facility nurse and home health attempted to check R1’s leg and feet. R1 refused help and requested their personal doctor instead. Additionally, R1 used to walk around the facility barefoot, so the former ED bought two (02) pairs of slippers for them to wear. Interview with R1 revealed the facility properly cared for the scratch on their leg. R1 received an antibiotic to reduce an infection. R1 also confirmed the former ED bought them slippers for their feet and ordered home health visits three (03) times per week to heal the wounds on their feet. R1’s physician told them their cellulitis was cured, but R1 disagreed and applied for a different home health agency. R1 believed their cellulitis was finally resolved after visits from the home health agency they had chosen. Based on interviews, the facility properly addressed R1’s medical needs in a timely manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5