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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610362
Report Date: 06/26/2025
Date Signed: 06/26/2025 11:53:35 AM

Document Has Been Signed on 06/26/2025 11:53 AM - 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:ANTORIA ASSISTED LIVING OF TARZANAFACILITY NUMBER:
197610362
ADMINISTRATOR/
DIRECTOR:		CAMPOS, MARYCELFACILITY TYPE:
740
ADDRESS:5912 CAHILL AVENUETELEPHONE:
(626) 840-2830
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 6CENSUS: 2DATE:
06/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Eleanor VelascoTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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At approximately 9:15 a.m. on 06/26/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit.

The facility was last visited on 05/01/24 for an annual inspection. It is a single-story building with seven (07) bedrooms, four (04) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for 6 non-ambulatory residents, of which one (01) may be bedridden in Bedroom #5 or #6. Approved hospice waivers for six (06).

The front yard was maintained and contained a carport and ramps in good condition. At the main entrance, LPA observed postings for COVID precautions, a blank copy of the admission agreement, confidential complaint contacts, Ombudsman contacts, facility license, administrator certificate, house rules, personal rights, rights of resident councils, emergency disaster plan, theft and loss policy, activity schedule, and the lists of staff and residents. A sign was hung stating “No smoking – Oxygen in use”.

The facility has seven (07) bedrooms. One (01) bedroom near the laundry area served as a staff room. The staff room was attended 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. Both residents were observed relaxing in their rooms during the inspection.

Walls, floors, windows, screens, and blinds were clean and in good repair. The living room contained exercise equipment, reading material, board games, art supplies, an appropriately covered fireplace, and furniture in good repair. A linen closet in the hallway contained an adequate supply of fresh linens. At approximately 9:30 a.m. LPA measured the room temperature to be 75 degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: ANTORIA ASSISTED LIVING OF TARZANA
FACILITY NUMBER: 197610362
VISIT DATE: 06/26/2025
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At approximately 9:45 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 04/23/25. At 10:00 a.m. LPA called the house telephone and confirmed it to be operational. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. The stove hood was clean. A weekly menu was posted on the refrigerator. Appliances were in good condition. Sharps and confidential files were locked below the counter top. Medications were locked above the counter top. Cleaners were locked below the sink. A washing machine and dryer were located in a laundry area adjacent to the kitchen. Both were in working order. Detergents and cleaning solutions were locked above the appliances.

The facility has four (04) bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 10:10 a.m. LPA measured the water temperature in the bathroom near Bedroom #1 to be 109.9 degrees Fahrenheit.

LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition as well as small animals in cages. Hand rails were secure. The back yard contained a large gardened area and a locked storage shed with tools inside. All emergency exit paths were free from obstructions. Three (03) out of three (03) exit gates were unlocked with self-closing latches. Evacuation routes were posted. Fire sprinklers were observed throughout the house. At approximately 10:30 a.m., smoke and carbon monoxide detectors were tested and operational. At approximately 10:45 a.m., LPA and staff conducted a medication review. Resident medication counts accurately matched the amounts prescribed and documented.

LPA conducted a record review of personnel and resident files at 11:00 a.m. All files were complete and available for audit.

During today’s inspection, the facility is in compliance with Title 22 regulations. No immediate health or safety concerns were observed.

Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
LIC809 (FAS) - (06/04)
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