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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604926
Report Date: 01/20/2022
Date Signed: 01/20/2022 04:03:04 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: 4DATE:
01/20/2022
UNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Dina Pamatmat - AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident in a timely manner

Staff did not have knowledge of resident's needs or care plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with administrator Dina Pamatmat and explained the reason for the visit.

LPA conducted physical plant tour at 10:40 AM, requested facility documents relevant to the investigation at 11:00 AM and interviewed administrator and staff between 11:15 AM to 12:45 PM.

Regarding the allegation that Staff did not seek medical attention for resident in a timely manner, it was alleged that Resident #1 (R1) was found breathing, tachypneic, tachycardic and hypotensive and highly likely was in septic shock. LPA's interview with the staff present during the time of the incident revealed that on or about 4:00 PM on 11/16/21, during a routine hourly check, Staff #1 (S1) observed that R1 was having a shortness of breath and very pale so S1 called Staff #2 (S2) to confirm S1's observation and checked R1's vital (O2 sat and BP) (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
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 2
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: 01/20/2022
NARRATIVE
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(continued from LIC 9099)

When S2 realized that R1's vital reading is not good, S2 immediately called 911 at around 4:10 PM. While on 911 call, operator advised S2 to perform CPR to R1 so R2 did until the paramedics arrived within minutes and took over from S2.

Regarding the allegation that Staff did not have knowledge of resident's needs or care plan, it was alleged that staff members at the board and care had zero paperwork for the resident.

LPA's record review on 11/23/21 at 1:20 PM and today at 1:02 PM revealed that R1 had complete documentation at the facility including but not limited to: Updated Physician's report (LIC 602), Updated Resident appraisal (LIC 603A), Identification and Emergency information (LIC 601) and list of medication and advanced health directive that the paramedics required. LPA's interview with administrator today at 1:20 PM also revealed that R1 used to be on Hospice but was taken off hospice two (2) years ago and the family did not want for R1 to have a DNR (Do Not Resuscitate).

Based on the information gathered during this and prior visit, the allegations are 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: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2