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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604926
Report Date: 11/26/2024
Date Signed: 11/26/2024 12:47:36 PM

Document Has Been Signed on 11/26/2024 12:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TARZANA MANORFACILITY NUMBER:
197604926
ADMINISTRATOR/
DIRECTOR:		DINA F. PAMATMATFACILITY TYPE:
740
ADDRESS:18162 RANCHO STREETTELEPHONE:
(818) 807-3050
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 6CENSUS: 4DATE:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jose Aldeson BistaTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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At 10:00 a.m. on 11/26/2024, Licensing Program Analysts (LPAs) Nicholas Reed and Angelica Segovia conducted an unannounced annual inspection. LPAs met with staff and disclosed the reason for the visit. LPAs contacted the licensee by telephone at approximately 10:30 a.m. and disclose the reason for the visit.

A file review was conducted prior to today’s visit.

The facility was last visited on 03/15/2024 for a complaint visit. It is a single story building with five (05) bedrooms, three (03) bathrooms, kitchen, laundry room, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which five (05) may be bedridden. Approved hospice waivers for five (05).

LPA observed a maintained front yard. A screening station at the front contained surgical masks, N95 masks, sanitizer, a digital thermometer, and a visitor log. Postings at the front included COVID precautions, facility license, confidential complaints contacts, ombudsman contacts. Additional postings near the kitchen included the emergency disaster plan, rights of resident councils, personal rights, and the facility sketch.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:20 a.m. LPAs measured the room temperature to be 76 degrees Fahrenheit. Three (03) residents were observed in the dining room drinking tea. Two (02) staff members were observed cleaning and preparing lunch.

The living room contained a television, reading material, exercise equipment, and furniture in good repair. A fireplace was appropriately covered and turned off. Medications were locked near the main entrance.

The facility has five (05) bedrooms. One (01) bedroom is designated as a staff room. The staff room was unlocked and free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All rooms had hospital beds with wheels in the locked position.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: TARZANA MANOR
FACILITY NUMBER: 197604926
VISIT DATE: 11/26/2024
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The facility has three (03) bathrooms. Two (02) bathrooms are private to Bedrooms #3 and #4, and one (01) is shared. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 10:30 a.m. LPAs measured the water temperature in Bathroom #1 to be 112.5 degrees Fahrenheit.

LPAs called the house telephone at 10:40 a.m. The phone was deemed operational. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. Appliances were in good condition. Sharps and cleaning solutions were locked under the sink. The stove surface and hood were clean.

A washing machine and dryer were located in the laundry area. Both were in working order. Detergents and cleaning supplies were locked near the appliances.

LPA observed a patio area in the rear of the facility. The patios contained furniture in good condition.

All emergency exit paths were free from obstructions. Exit gates were unlocked. Four (04) out of four (04) auditory alarms were turned on and functioning. Fire sprinklers were located throughout the facility. At 12:25 p.m., smoke and carbon monoxide detectors were tested and operational. At approximately 12:35 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last tested on 05/20/2024 with a tag attached.

At 11:00 a.m. LPAs reviewed staff and resident files. All files were complete and available for audit.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health or safety hazards were observed.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
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