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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608081
Report Date: 01/25/2022
Date Signed: 01/25/2022 05:41:21 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: 112DATE:
01/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carolina Garcia'TrejoTIME COMPLETED:
05:50 PM
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Licensing Program Analyst (LPA) Yelena Avetisyan conducted an unannounced required annual inspection to the facility. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Carolina Garcia'Trejo and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The dining room furniture was observed to be in good condition. Per administrator they are currently not using the dinning room in Assisted Living as a precaution.

BEDROOMS: The LPA observed randomly selected resident rooms, which were furnished appropriately with clean linens, furnishings and sufficient lighting. LPA observed carpeting stained/dirty and blind broken in residents rooms. A discussion was held with the administrator who stated they will be shampooing the carpets once dinning room is opened. Administrator also agreed to inspect all resident rooms, create a maintenance log to document all rooms that need repairs. She will then ensure that maintenance completed the required repairs.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Bathrooms are sufficiently stocked with hand liquid soap and paper towels.

COMMON SPACES: Common areas include the dining room, activity room and patio. In the common areas, walls, flooring and furniture were checked for cleanliness and good condition. The fire extinguisher in the hallways were fully charged and was last serviced 3/2021. Required postings were observed throughout the common hallways in Assisted Living but were not posted in memory care. Administrator agreed to post the required postings in Memory Care.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 TARZANA
FACILITY NUMBER: 197608081
VISIT DATE: 01/25/2022
NARRATIVE
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Record Reviews: LPA conducted review or resident and staff files from approximately 10:45 am to 1:00 pm and observed the following.
  • Licensee does not have current physicians report for 7 out of 7 resident who have a diagnosis of Major Neurocognitive disorder.
  • Licensee does not have current/completed hospice care plan for 7 out of 7 residents who are currently receiving hospice services. A discussion was held with the administrator on 10/20/2021 regarding obtaining current, complete hospice care plans for all residents.
  • 2 out of 7 hospice residents utilize full bed rails however licensee does not have hospice care plan that indicates the need for the full rails
  • 5 out of 7 residents are utilizing half rails however licensee does not have physician orders to utilize the rails.
  • Licensee is retaining bedridden residents in rooms that do not have bedridden fire clearance. (Rm 201, 12 A & 12 B, 229 A)
  • At 2:24 pm LPA spoke with the administrator regarding ambulatory status of for the 24 hospice residents. Administrator informed the LPA that 8 of the resident are unable to independently reposition in bed and are considered bedridden. 4 of the 8 residents are residing in rooms that do not have bedridden fire clearance.

Staff records were reviewed and observed to be complete with the required documentation. All staff have criminal record clearance and are associated to the facility. While reviewing staff files LPA observed 6 out of 8 staff do not have required training. 2 out of 2 newly hired staff training verification was not properly documented. Staff do not have current first aid/CPR training. A discussion was held with the administrator who stated she will review staff files and schedule training for all staff who do not have the required annual training's, including first aid/CPR,

Also during today's visit while conducting a tour of the facility at 1:05 pm LPA was informed by the administrator that beginning of January they had 2 residents who tested positive for COVID. LPA was informed that incident reports were faxed to the Woodland Hills South Regional office, however while reviewing the report LPA observed that the fax number was not for the department.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 TARZANA
FACILITY NUMBER: 197608081
VISIT DATE: 01/25/2022
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INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) in storage and the facility is able to obtain additional supplies as needed. The LPA observed resident and staff temperature logs, visitation screening questions, and cleaning log. The facility’s cleaning protocol is sufficient. Staff and residents were observed wearing face coverings. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA and Administrator discussed the recent PIN as it relates to visitation and staff vaccination requirements. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. This facility keeps track of vaccination rates for current staff. The facility’s policies and procedures as it pertains to infection control are adequate.

Prior to the completion of the visit LPA requested for the following to be submitted.

  • Documentation to change the administrator of the facility to Carolina Garcia'Trejo.
  • Copy of current Liability insurance.

Exit interview conducted. Copy of Report citations and Civil Penalties emailed to the administrator.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 TARZANA
FACILITY NUMBER: 197608081
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
FIRE CLEARANCE. All facilities shall maintain a fire clearance. Prior to accepting persons over 60 years of age none ambulatory and/or bedridden the licensee shall notify the licensing agency and obtain an appropriate fire clearance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above retaining 4 bedridden residents in rooms that do not have bedridden fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2022
Plan of Correction
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Licensee/Administrator will notify the Department how they will correct the cited deficiency. Licensee/Administrator can submit an LIC 200 and facility sketch to identify additional rooms they would like to obtain bedridden fire clearance or move the identified residents to proper fire cleared room.
This is a zero tolerance violation therefore civil penalty in the amount of $500 has been issued. Civil penalties in the amount of $100 dollars per day will accrue until POC is completed.
Type A
Section Cited
CCR
87608(a)(5)(B)
Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above by utilizing full bed rails for hospice residents without obtaining a hospice care plan that indicates the need for the full rails which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2022
Plan of Correction
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Licensee/administrator will tour rooms for all hospice residents and identify those who are utilizing full and/or half bed rails. Licensee/Administrator will contact the hospice agencies and obtain current hospice care plans which indicate the need for the full rails or order for half rails. Copies of the hospice care plans will need to be submitted as POC.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2022
LIC809 (FAS) - (06/04)
Page: 4 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 TARZANA
FACILITY NUMBER: 197608081
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports. A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. The licensing agency is authorized to require additional documentation if needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above by utilizing half bed rails for 6 residents without a written order from the physician which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2022
Plan of Correction
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Licensee/administrator will tour rooms for all residents and identify those who are utilizing bed rails. Licensee/Administrator will contact the physicians and obtain order for postural support for those identified as not having one. Administrator will submit the names of the residents room numbers and dates the orders were obtained as POC.
Type B
Section Cited
CCR
87705(c)(5)(A)
Licensees who accept & retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment, & a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not ensuring 7 out of 7 residents diagnosed with Dementia had an annual medical assessment and reappraisal which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2022
Plan of Correction
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Licensee/Administrator will review files for all residents diagnosed with dementia and identify those residents who need a current medical assessment and reappraisal. Licensee/Administrator will obtain the required records. Licensee/administrator will submit the names of the residents, room numbers and dates the updated physicians reports were obtained and re-appraisals completed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2022
LIC809 (FAS) - (06/04)
Page: 5 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 TARZANA
FACILITY NUMBER: 197608081
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87633(b)
A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not retaining current complete hospice care plan as required by title 22 for 7 out of 7 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2022
Plan of Correction
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Licensee/Administrator will review the regulation and records for all 22 residents. Administrator will obtain current, complete hospice care plans for all residents. Administrator will submit the names of all the hospice residents, room numbers and indicate the date the hospice care plans were obtained and indicate that all information required by Title 22 are documented on the care plans. .
Type A
Section Cited
CCR
87211(a)(2)
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not properly notifying the department when 2 residents tested positive for COVID-19. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2022
Plan of Correction
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Licensee/Administrator will notify the department in writing what steps will be taken to prevent a repeat violation of this regulation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2022
LIC809 (FAS) - (06/04)
Page: 6 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 TARZANA
FACILITY NUMBER: 197608081
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not ensuring staff receive required annual training as it relates to their job duties which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2022
Plan of Correction
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Licensee/Administrator will schedule required training including first aid/CPR for all staff. Verification of staff training with the trainers credentials, copies of training materials will need to be submitted as POC.
Type B
Section Cited
CCR
87412(c)(2)
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.
(2) Documentation of staff training shall include: (A) Trainer’s full name; (B) Subject(s) covered in the training; (C) Date(s) of attendance; and (D) Number of training hours per subject.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not properly documenting staff training
which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2022
Plan of Correction
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Licensee/Administrator will review the regulation and submit a written statement indicate that they understand and will ensure to properly document staff training at all times.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2022
LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 TARZANA
FACILITY NUMBER: 197608081
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)(5)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by not ensuring staff received training on infection prevention, symptoms, transmission and PPE use by an individual trained in infection control and not ensuring staff are fit tested for N95 masks as required and indicated in the licensees mitigation plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2022
Plan of Correction
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Licensee/Administrator will schedule training for all staff to be provided by an individual trained in infection control and schedule all staff to be fit tested for N95 masks. Verification of the scheduled training with the trainers credentials nd lwill need to be submitted by 1/27/2022 and verififcation of compeleted training will need to be completed by 2/3/2022.Fit testing will also need to be scheduled by 1/27/2022 urs and completed by 2/3/2022 days. Licensee/Administrator will email LPA with the scheduled testing dates and locations for all staff and submit documentation once fit testing is completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2022
LIC809 (FAS) - (06/04)
Page: 8 of 9