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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604926
Report Date: 11/23/2021
Date Signed: 11/23/2021 04:27:51 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
11/18/2021 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20211118162835
FACILITY NAME:TARZANA MANORFACILITY NUMBER:
197604926
ADMINISTRATOR:DINA F. PAMATMATFACILITY TYPE:
740
ADDRESS:18162 RANCHO STREETTELEPHONE:
(818) 807-3050
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:6CENSUS: 5DATE:
11/23/2021
UNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Jose Alderson Bista - StaffTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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9
Staff did not meet resident's hygiene needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA met with staff Jose Alderson Bista and explained the reason for the visit.

LPA conducted physical plant tour at 9:20 AM, requested copy of facility documents relevant to the investigation at 9:45 AM and conducted interview with staff and residents from 10:00 AM to 1:00 PM. Regarding the allegation that the staff did not meet's resident's hygiene needs, it was alleged that resident have not been cleaned for sometime and having bodily fluids stains on her torso. LPA interview with Staff #1 (S1) at 10:45 AM, revealed that during episode of Resident #1 (R1) having a cardiac arrest, R1 had vomited on own clothes while S1 was trying to revive R1 via CPR upon the instruction and guidance of the 911 operator while waiting for the paramedics to arrive. LPA's interview with Staff #2 (S2) at around 10:00 AM, also revealed that R1 was cleaned and changed prior to S2 leaving the facility for a medical check up which is less than two (2) hours prior to the cardiac arrest episode of R1. Further, LPA's observation at 9:20 AM also revealed that all the residents currently living at the facility are neat and clean and properly dressed. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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 3
Control Number 31-AS-20211118162835
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: TARZANA MANOR
FACILITY NUMBER: 197604926
VISIT DATE: 11/23/2021
NARRATIVE
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(continued from LIC 9099)

LPA's interview with two (2) alert residents also revealed that staff take good care of them and meet all their care and hygiene needs.

Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3