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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608081
Report Date: 02/11/2021
Date Signed: 02/11/2021 04:34:57 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:
02/11/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Erin MahoneyTIME COMPLETED:
04:15 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 received an incident report on 2/10/21 where resident #1 (R1) alleged that they were being hit by staff in their side while lying down in bed. LPA conducted an interview with the administrator regarding this incident report. R1's responsible party came to the administrator on 2/5/21 and stated that their parent told them this. R1 stated that the laundry lady did this to her. After receiving the information from R1's responsible person, administrator made the decision that when R1 is being assisted it would be a two person assist at all times until further notice. On 2/6/21 administrator met with R1 regarding the allegation. R1 stated they were hit in the back while sitting up in their bed but didn't know who did it. A body check was done and there was no bruising, redness, or scratching to indicate physical abuse. Administrator began interviews with approximately 18 staff members, a hospice care worker, and four residents one of which who is R1's roommate. Administrator also made a report to Adult Protective Services, Long Term Care Ombudsman, and the police department. Due to the need for more information at this time more investigation is needed into what was alleged. 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: 02/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021
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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