197610366-8-22-2023-31-AS-NMAN-CW5UN6-20230929154326

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610366
Report Date: 08/22/2023
Date Signed: 08/22/2023 04:21:39 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/16/2023 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20230516122901

FACILITY NAME:	SUMMIT ASSISTED LIVING OF TARZANA		FACILITY NUMBER:	197610366
ADMINISTRATOR:	NIRJARA ACHARYA		FACILITY TYPE:	740
ADDRESS:	5711 RESEDA BLVD		TELEPHONE:	(818) 996-2022
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	176	CENSUS: 38	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Carmelita Roxas		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident's room was in disrepair for an extended period of time.
Staff are not providing activties for residents.
Staff are threatening residents.
Staff left resident in soiled diapers for an extended period of time.
Staff did not safeguard residents personal belongings.
Staff are emotionally abusing resident.
Staff did not keep resident's personal information confidential.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegations. LPA met with the Wellness Coordinator, Carmelita Roxas, and explained the reason for the visit. The Executive Director, David Aguiniga, designated Carmelita Roxas as the responsible person to sign and accept this report.

--- Resident's room was in disrepair for an extended period of time.

It was alleged that Resident #7’s (R7) room was flooded due to the pipes being backed up. To investigate the allegation on 05/17/2023 LPA conducted physical plant tour at around 10:00 AM, interviewed staff at 11:30 AM, and interviewed residents at 01:30 PM. During the physical plant tour, LPA did not observe damage or any signs of past damage in the R7’s room.

(CONT. on LIC 812-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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 4

Control Number 31-AS-20230516122901

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/22/2023

NARRATIVE

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During interviews with staff, all staff stated that they were unaware or did not recall any damage that may have led to flooding a resident’s room. During interviews with residents, Resident #1 (R1) stated there was a leak in one of the resident’s rooms, but not to the point of flooding and believes they fixed it right away. All other residents stated they did not know about any flooding in any of the rooms.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff are not providing activities for residents.

It was alleged that residents do not have an activities coordinator, do not have sufficient activities, and are put in front of televisions all day. To investigate the allegation on 05/17/2023 LPA conducted physical plant tour at around 10:00 AM, interviewed staff at 11:30 AM, and interviewed residents at 01:30 PM. During the physical plant tour, LPA observed a fully scheduled activities calendar, an activities coordinator and residents participating in activities with the coordinator. During interviews with staff, all staff stated they have an activities coordinator, have plenty of activities for the residents to participate in, but that they only encourage and do not force residents to participate. During interviews with residents, all residents stated that facility has activities for residents to participate in.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff are threatening residents

It was alleged that residents are scared to speak to officials because staff threatens residents. To investigate the allegation on 05/17/2023, LPA interviewed staff at 11:30 AM, and interviewed residents at 01:30 PM. During interviews with staff, all staff stated they never threaten residents or discourage them from speaking to anyone. During interviews with residents, all residents stated they are never threatened by staff and can speak freely to whomever they wish.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

(CONT on LIC 812-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 31-AS-20230516122901

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/22/2023

NARRATIVE

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--- Staff left resident in soiled diapers for an extended period of time.
It was alleged that residents are left soiled for an extended time. To investigate the allegation on 05/17/2023 LPA conducted physical plant tour at around 10:00 AM, interviewed staff at 11:30 AM, and interviewed residents at 01:30 PM. During the physical plant tour, LPA observed that all residents were clean and well-groomed, and LPA did not experience any malodor. During interviews with staff, all staff stated they check on all incontinent residents every two hours, change them three times a day minimum or as needed and do not leave residents soiled for an extended time. During interviews with residents, all residents stated that the facility checks on them regularly, assists those that require incontinent care and do not leave residents soiled for and extended time.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff did not safeguard residents’ personal belongings.

It was alleged that staff use residents’ sanitary products for other residents without replacing them. To investigate the allegation on 05/17/2023, LPA interviewed staff at 11:30 AM, and interviewed residents at 01:30 PM. During interviews with staff, all staff stated they never use other residents’ products or supplies to provide care to other residents and that each resident has their own supplies. During interviews with residents, all residents stated staff have never used their personal supplies to provide care to other residents.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff are emotionally abusing resident

It was alleged that staff emotionally abuse residents. To investigate the allegation on 05/17/2023, LPA interviewed staff at 11:30 AM, and interviewed residents at 01:30 PM. During interviews with staff, all staff stated they never emotionally abuse residents and treat them all with respect and dignity. During interviews with residents, all residents stated staff have never emotionally abused them or other residents.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
(CONT on LIC 812-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20230516122901

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/22/2023

NARRATIVE

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--- Staff did not keep resident's personal information confidential.

It was alleged that staff discuss residents’ medical information in front of other residents. To investigate the allegation on 05/17/2023, LPA interviewed staff at 11:30 AM, and interviewed residents at 01:30 PM. During interviews with staff, all staff stated they never discuss the resident’s medical information in front of other residents or non-staff members. During interviews with residents, all residents stated staff never discuss the resident’s medical information in front of other residents or non-staff members.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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