When inspectors arrived at Tarzana Health and Rehabilitation Center on November 21, they found the lobby's Temperature Control Box 2 switched off at 9:45 a.m. A medical assistant told them the staff member responsible for turning it on each morning at 7:30 a.m. "had been busy and occupied with other tasks."
The medical assistant turned the system on during the inspection, setting the temperature to 72 degrees.
One resident's family member had noticed the problem long before inspectors arrived. During a phone interview, Family Member 1 told investigators that whenever they met Resident 1 in the facility lobby, "Resident 1's hands were always cold, and Resident 1 appeared to be cold at all times."
The facility's own policy requires temperatures between 71 and 81 degrees in all areas where residents spend time. The Director of Nursing confirmed this range during an interview, then admitted the facility's written policy was wrong. It specified 72 to 82 degrees instead of the required 71 to 81 degrees.
"The facility would need to revise its Policy and Procedure to reflect the correct required temperatures range," the Director of Nursing told inspectors.
The temperature monitoring problems ran deeper than one cold morning. The Maintenance Supervisor revealed during a record review that staff had only been checking temperatures in residents' rooms for the two years he had worked there. Nobody was documenting lobby temperatures at all.
"The facility had only been documenting temperatures for residents' rooms, not for other areas," the Maintenance Supervisor told inspectors while reviewing October and November temperature logs.
The Maintenance Supervisor said staff had been checking lobby temperatures when they checked room temperatures, but never wrote them down. He promised to start adding lobby temperature checks to the official log.
Federal regulations require nursing homes to maintain comfortable temperatures in all areas where residents spend time. The facility's own policy acknowledges this, stating that "comfortable and safe temperature levels" should minimize residents' risk of losing body heat and developing hypothermia or hyperthermia.
The policy specifically lists areas that must be monitored: "residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas." It requires temperatures in common areas to stay "between 72 and 82 degrees Fahrenheit."
Yet for two years, nobody had been documenting whether the lobby met those requirements.
The violation occurred despite the facility having written procedures in place. The policy, last reviewed in April 2025, describes temperature control as essential for resident safety and comfort. It warns that improper temperatures can make residents susceptible to "loss of body heat and risk of hypothermia/hyperthermia."
The November morning when inspectors found the heating system off represented a breakdown in the facility's basic daily operations. The medical assistant's explanation that the responsible staff member was "busy and occupied" suggests the morning heating routine had become inconsistent.
For Resident 1's family member, the cold lobby had become a regular concern during visits. The family member's observation that the resident's hands were "always cold" and that the person "appeared to be cold at all times" indicates the temperature problems affected residents directly.
The inspection found the facility failed to maintain required environmental conditions for resident health and comfort. Staff had developed a gap between their actual practices and their written policies, checking some temperatures while ignoring others, and occasionally forgetting basic climate control entirely.
The Maintenance Supervisor's promise to begin documenting lobby temperatures came only after inspectors discovered the two-year gap in monitoring. Until that November morning, no one in authority had questioned why temperature logs covered residents' rooms but not the common areas where residents spent significant time with family members.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tarzana Health and Rehabilitation Center from 2025-11-21 including all violations, facility responses, and corrective action plans.
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