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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608081
Report Date: 02/12/2021
Date Signed: 02/13/2021 12:06:09 PM

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:AVANTGARDE SENIOR LIVING OF TARZANAFACILITY NUMBER:
197608081
ADMINISTRATOR:ERIN MAHONEYFACILITY TYPE:
740
ADDRESS:5645 LINDLEY AVENUETELEPHONE:
(818) 881-0055
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:138CENSUS: 108DATE:
02/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Erin MahoneyTIME COMPLETED:
07:00 PM
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Licensing Program Analyst (LPA) Wendell Smith conducted a case management visit to this facility. Due to the situation surrounding the Corona Virus Disease 2019 (COVID-19) and to implement mitigation measures, today’s case management visit was conducted telephonically with facility Administrator Erin Mahoney.

LPA is finishing up on a serious incident report reported on 2/10/21. LPA previously conducted a case management visit on 2/11/21 regarding this incident. There was an incident where resident #1 (R1) alleged that they were being hit by staff in their side while lying down in bed. Interviews were conducted with residents and facility staff. A medical evaluation was also conducted by R1's primary care physician (PCP). Evaluation found there was no signs of abuse found on R1 or any staff misconduct. Also R1's primary care physician believes that R1 is confused and disoriented. R1 was also interviewed by their PCP and denied being hit by anyone. Based on the information obtained through interviews and documentation there is no further action that is necessary. Exit Interview conducted. Copy of report emailed for signature.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
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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