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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609918
Report Date: 01/31/2022
Date Signed: 01/31/2022 12:36:49 PM

Document Has Been Signed on 01/31/2022 12:36 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TARZANA SENIOR LIVING INCFACILITY NUMBER:
197609918
ADMINISTRATOR:AYVAZYAN, SARGISFACILITY TYPE:
740
ADDRESS:5236 OTIS AVETELEPHONE:
(747) 253-0007
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 6CENSUS: DATE:
01/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Sargis AyvazyanTIME COMPLETED:
12:50 PM
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At 10:20 a.m. Licensing Program Analyst (LPA) Melissa Ruiz conducted an unannounced annual inspection at this facility. LPA were greeted by staff and later met with Administrator Sargis Ayvazyan. No covid-19 signage was posted outside the facility. Upon entrance, hand sanitizer was observed, and LPA’s temperature was taken, was asked to sign in the visitor’s log but was not asked any infection control questions. LPA observed sufficient PPE supplies for residents and staff. LPA reminded the Administrator to follow their mitigation plan to ensure staff was following proper infection control protocols. Inspection: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen however garbage cans throughout the facility did not have tight fitting lids. LPA advised the Administrator to purchase garbage cans with tight fitting covers. Sharps are kept inaccessible to residents. Medications are in a centrally stored and are kept locked in a medication closet. Smoke detectors/carbon monoxide were located throughout the facility and appear to be operational. Resident rooms: There are 6 bedrooms designated for resident use and 1 bedroom designated for staff use. All bedrooms are properly furnished, have appropriate bedding, and linens. Bathrooms: The hot water temperature measured at 107.6 F. Residents observed to have plenty of supplies for personal hygiene products. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor seating, with various covered shaded areas for clients. There are no bodies of water.

No deficiencies observed at this time. Exit interview conducted and report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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