197610366-5-4-2026-31-AS-NMAN-DU3S4F-20260514133241

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610366
Report Date: 05/04/2026
Date Signed: 05/04/2026 02:03:41 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
11/20/2025 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20251120091051

FACILITY NAME:	SAVANT OF TARZANA		FACILITY NUMBER:	197610366
ADMINISTRATOR:	NARINE MERTKHANYAN		FACILITY TYPE:	740
ADDRESS:	5711 RESEDA BLVD		TELEPHONE:	(818) 996-2022
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	176	CENSUS: 130	DATE:	05/04/2026
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Narine Mertkhanyan		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Due to improper care, resident developed unstageable pressure injury

INVESTIGATION FINDINGS:

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At approximately 8:30 a.m. on 05/04/26 Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager Naira Margaryan (LPM) conducted a 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 11/20/25 and interviewed staff and residents between 2:00 p.m. and 2:20 p.m., requested pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and client roster at 2:15 p.m., and toured the facility inside and out at 2:25 p.m. The Department conducted further staff and witness interviews between 12/08/25 and 03/18/26 and obtained and reviewed hospital records on 12/19/25. Today, LPA toured the facility at 09:30 a.m. At 10:30 am, LPM and LPA discuss the allegation with ED and the Vice President (VP) of Health and Wellness.
Regarding the allegation "Due to improper care, Resident developed unstageable pressure injury” it was alleged the facility did not seek the necessary incidental medical care and services for Resident #1 (R1) which led to an unstageable pressure injury on their left heel. Staff interviews revealed on 11/07/25, redness was noted on R1’s left heel, and R1 expressed some pain.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026

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-20251120091051

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: 05/04/2026

NARRATIVE

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Caregivers notified the Wellness Director (WD) and Wellness Coordinator (WC). On 11/09/25 redness was noticed on both of R1’s heels at the pressure points. Staff were instructed to put a pillow under R1’s heel to offload the pressure. Although R1’s skin condition was observed by appropriate personnel, no proper skin assessment was provided, and R1’s skin condition was not discussed with their doctor or other skilled professionals. On 11/10/25 and 11/13/25, staff notified R1’s family of the redness on their heels. Multiple staff noticed R1 screaming since 11/07/25. Between 11/07/25 and 11/18/25 conditions of R1’s pressure injuries got worse. On 11/18/25, R1 was sent to the hospital to seek medical attention.

A review of facility records revealed the following information: Caregiver notes from 11/07/25 identified redness on R1’s left heel. R1 expressed some pain. By 11/09/25, redness was noticed on both of R1’s heels. On 11/10/25 and 11/13/25, the condition of the pressure injuries worsened. Staff continued to monitor R1’s condition by putting pillows under their heels to keep their legs elevated, though R1’s care plan was not updated with this procedure. Further review of facility records revealed although facility staff had knowledge that R1’s pressure injuries were getting worse, no initial and continued wound assessment were completed. The doctor was not notified to properly assess the wound and assign skilled medical professionals to provide required medical care.

Overall investigation revealed that on 11/07/26, while in the facility, R1 developed pressure injuries. Between 11/07/25 and 11/18/25, the condition of the pressure injuries got worse, and facility did not take appropriate steps to ensure R1 is receiving required medical care and other services. On 11/18/26 R1 was sent to the hospital with unstageable wound on their left heel. Therefore, based on interviews and record reviews the allegation is deemed SUBSTANTIATED at this time. A $500 immediate civil penalty is assessed today for a violation resulting and immediate health and safety risk to R1’s health and safety. The ED was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

No immediate health or safety concerns observed during today’s visit.

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

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 31-AS-20251120091051

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: 05/04/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/05/2026 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	87464 Basic Services (d) A facility... shall be responsible for meeting the resident's needs... and providing... other basic services... either directly or through outside resources. This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Licensee to review facility program plan and update procedures regarding resident reassessments, hospital discharges, and care plan updates and submit proof by the POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above by not providing appropriate services for Resident #1 (R1) which posed an immediate threat to the Health, Safety, or Personal Rights of persons in care.	8 9 10 11 12 13 14
CCR	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.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026

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
11/20/2025 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20251120091051

FACILITY NAME:	SAVANT OF TARZANA		FACILITY NUMBER:	197610366
ADMINISTRATOR:	NARINE MERTKHANYAN		FACILITY TYPE:	740
ADDRESS:	5711 RESEDA BLVD		TELEPHONE:	(818) 996-2022
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	176	CENSUS: 130	DATE:	05/04/2026
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Narine Mertkhanyan		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff changed residents healthcare provider without consent of resident or residents responsible party

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026

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-20251120091051

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: 05/04/2026

NARRATIVE

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Regarding the allegation “Staff changed residents healthcare provider without consent of resident or residents responsible party” it was alleged facility staff switched the insurance of Resident #1 (R1) without consent. Interviews with Staff #6 (S6) at 2:05 p.m. on 11/20/25 and Staff #4 (S4) at 2:15 p.m. on 11/20/25 revealed they had no knowledge of R1’s insurance coverage or changes. Interview with the administrator at 11:45 a.m. today revealed R1 never returned to the facility after their hospitalization on 11/18/25. The administrator also had no knowledge about R1’s insurance coverage or change. Interview with Witness #1 (W1) at approximately 2:00 p.m. on 02/13/26 revealed a dispute in the rental agreement affected R1’s insurance. Staff #7 (S7) requested W1 to switch R1’s insurance in order to qualify for a government program. Interview with S7 at 12:15 p.m. today confirmed they requested R1 to switch insurance, but it never happened. W1 also confirmed R1’s insurance was never changed. No records reviewed indicated R1’s insurance was switched. Based on interviews and record review, staff did not change R1’s healthcare provider. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health or safety concerns observed during today’s visit.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 5