197610366-7-16-2024-31-AS-NMAN-D7UVM2-20240805163249

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610366
Report Date: 07/16/2024
Date Signed: 07/16/2024 04:23:55 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
12/19/2023 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20231219103438

FACILITY NAME:	SAVANT OF TARZANA		FACILITY NUMBER:	197610366
ADMINISTRATOR:	JINA MALEKSARKISSIANS		FACILITY TYPE:	740
ADDRESS:	5711 RESEDA BLVD		TELEPHONE:	(818) 996-2022
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	176	CENSUS: 75	DATE:	07/16/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Rita Meldonian		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Staff do not provide proper transportation assistance to resident's medical appointments

INVESTIGATION FINDINGS:

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At 9:15 a.m. on 07/16/24, 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 allegations above, LPA conducted an initial visit on 12/21/23 and toured the facility at 11:15 a.m., interviewed the previous ED and staff between 11:30 a.m. and 1:00 pm., and reviewed records pertinent to the investigation, including but not limited to an incident report, an abuse report, identification, admission agreement, appraisal, emergency contacts, and a medical assessment at 1:30 p.m. LPA conducted a subsequent visit on 05/29/24 and interviewed resident #1 (R1) at 9:30 a.m. Today, LPA toured the facility at 10:00 a.m. and interviewed additional staff between 9:45 a.m. and 3:30 pm.

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: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

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 6

Control Number 31-AS-20231219103438

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: SAVANT OF TARZANA	FACILITY NUMBER: 197610366
	VISIT DATE: 07/16/2024

NARRATIVE

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Regarding the allegation “Staff do not provide proper transportation assistance to resident's medical appointments” it was alleged R1 has been late to and left at dialysis appointments. Interview with R1 revealed they had switched health insurance providers which limited their transportation options. R1 required transportation to and from dialysis appointments which were scheduled between 12:00 p.m. to approximately 3:00 p.m. When the facility transported R1 to their dialysis, there were “three (03) to four (04) times” when R1 was “stranded” there until 4:00 p.m. or 4:30 p.m. Interview with the former ED at 11:30 a.m. on 12/21/23 revealed the facility could not exactly fit R1’s schedule due to other residents who required transportation. In total, the facility missed one (01) of R1’s appointment’s. The previous ED spoke with R1’s dialysis agency to coordinate future visits. Interview with Staff #1 (S1) at 12:00 p.m. on 12/21/23 revealed the facility pick up and drop off times “may not match” R1’s appointment times. Interview with Staff #3 (S3) at 12:30 p.m. on 12/21/23 revealed the facility shuttle would leave around 11:30 a.m. to get to R1’s noon appointment, and one (01) time, R1 was left waiting for a while. The facility shuttle went there right away when staff had found out. Interview with Staff #8 (S8) at 1:00 p.m. on 12/21/23 revealed they would drive R1 to their dialysis appointments and wait with R1 if they arrived early. At times, R1 would say they were ready, but S8 had to wait approximately to thirty (30) minutes for R1’s blood to clot. S8 stated there was one (01) occasion when R1 had to wait to be picked up due to other residents requiring transportation. Based on interviews, the facility did not provide proper transportation to at least one (01) of R1’s dialysis appointments. Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is cited on the corresponding LIC 9099-D page.

No immediate health and safety risks were observed during today’s 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: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 31-AS-20231219103438

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: SAVANT OF TARZANA	FACILITY NUMBER: 197610366
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/16/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 07/26/2024 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan... shall be developed... (2) ...in meeting necessary medical and dental needs. This includes transportation... directly or... arrangements. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee has agreed to review all schedules of resident dialysis and submit a document indicating transportation arrangements by the POC due date.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above in at least one (01) out of seventy five (75) residents which poses a potential Health, Safety, or Personal Rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
12/19/2023 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20231219103438

FACILITY NAME:	SAVANT OF TARZANA		FACILITY NUMBER:	197610366
ADMINISTRATOR:	JINA MALEKSARKISSIANS		FACILITY TYPE:	740
ADDRESS:	5711 RESEDA BLVD		TELEPHONE:	(818) 996-2022
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	176	CENSUS: 75	DATE:	07/16/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Rita Meldonian		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Staff did not report incident to resident's responsible party
Staff do not clean resident's room
Staff do not keep resident's room free of odors
Staff do not provide adequate food service to resident

INVESTIGATION FINDINGS:

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Unsubstantiated

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: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

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 6

Control Number 31-AS-20231219103438

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: SAVANT OF TARZANA	FACILITY NUMBER: 197610366
	VISIT DATE: 07/16/2024

NARRATIVE

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Regarding the allegation “Staff did not report incident to resident's responsible party” it was alleged the facility did not report an assault on R1 by another resident. Interview with R1 revealed they were shoved by their roommate around October of 2023 after an argument. R1 fell and bled, but no major injuries were sustained. Interview with Staff #1 (S1) at 3:00 p.m. on 03/06/24 revealed they observed the incident and reported it to their supervisor, Staff #2 (S2). Interview with S2 at 12:00 p.m. on 12/21/23 revealed they reported the incident to R1’s responsible party, physician, and Community Care Licensing on 10/28/23. LPA was unable to contact R1’s responsible party to confirm the report had been received. Record review revealed the incident was reported along with an abuse report. The reports detailed R1 required minor medical care. Both had fax receipts attached. Based on interviews and record review, the facility reported the incident to R1’s responsible party and other necessary parties. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff do not clean resident's room” it was alleged bloody sheets were left in R1’s room for five (05) days. Interview with R1 revealed they had bled on their sheets from the incident with their roommate, and staff left the sheets in a corner of the room. Interview with the previous ED, S1, S2, Staff #3 (S3) at 12:30 p.m. on 12/21/23, Staff #4 (S4) at 12:45 p.m. today, Staff #5 (S5) at 1:10 p.m. today, Staff #6 (S6) at 11:00 a.m. today, and Staff #7 (S7) at 3:15 p.m. today revealed no staff saw or remembered bloody sheets in R1’s room. S5 noted they provided care for R1 almost every day for extensive periods of time. R1 never mentioned bloody sheets to S5 nor did S5 observe dirty sheets in R1’s room. S4 noted they always cleaned R1’s room to their liking. Based on interviews, the facility sufficiently cleaned R1’s room. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff do not keep resident's room free of odors” it was alleged the facility did not address the odor in R1’s room. Interview with R1 revealed a rat had been stuck in a trap in their room which caused a strong odor. Interviews with seven (07) out of seven (07) staff revealed they did not detect an odor in R1’s room. S4 and S5 noted they never noticed a rat trap in the room. Based on interviews, the facility maintained R1’s room free of odors. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.
Regarding the allegation “Staff do not provide adequate food service to resident” it was alleged the facility did not provide dinner to R1 after they returned late from dialysis appointments and missed the scheduled dinner times. During the facility tour at 10:00 a.m., today LPA observed the facility meal times posted near the dining rooms.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 31-AS-20231219103438

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: SAVANT OF TARZANA	FACILITY NUMBER: 197610366
	VISIT DATE: 07/16/2024

NARRATIVE

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A sign showed Breakfast 7:30 a.m. – 9:00 a.m., Lunch 11:30 p.m. – 1:00 p.m., and Dinner 4:00 p.m. – 5:30 p.m. Interview with R1 revealed they usually returned around 4:30 p.m. and missed dinner. R1 was offered a sandwich or a burger, “but nothing good”. Interviews with the previous ED, Staff #9 (S9) at 9:45 a.m. today, and Staff #10 (S10) at 10:00 a.m. today revealed the facility always has sandwiches and snacks available to residents, and the kitchen staff can save dinner for a resident when they are notified. Interviews with three (03) other staff also revealed that R1 had not missed any meals. Based on interviews and observations, the facility provided adequate food service to R1. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health and safety risks were observed during today’s visit.

Exit interview conducted. 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: 07/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 6