197608081-6-26-2021-31-AS-NMAN-C56SU5-20210722141033

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608081
Report Date: 06/26/2021
Date Signed: 06/26/2021 03:36:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20200519131417

FACILITY NAME:	AVANTGARDE SENIOR LIVING OF TARZANA		FACILITY NUMBER:	197608081
ADMINISTRATOR:	ERIN MAHONEY		FACILITY TYPE:	740
ADDRESS:	5645 LINDLEY AVENUE		TELEPHONE:	(818) 881-0055
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	138	CENSUS: 103	DATE:	06/26/2021
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Jero Argota - Assistant Care Coordinator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility denied resident access to oxygen

Residents were forced into receiving hospice services

Facility gave false information to resident's family member

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit to this facility to further investigate the above stated allegations. LPA met wtih Assistant Care Coordinator Jero Argota and explained the reason for the visit. LPA also talked to the new Executive Director Carolina Garcia Trejo on the phone and designated Mr. Argota to sign the report.

At around 9:30 AM, LPA conducted physical plant tour. At 10:20, LPA requested copy of pertinent facility documents relevant to the investigation. At 11:00 AM, LPA conducted interview with staff and at 1:15 PM, LPA conducted interview with residents. Regarding the allegation that the facility staff denied resident oxygen, LPA record review revealed that Resident #1 (R1) had an outstanding order from Hospice Nurse dated 05/06/2020 that if R1 had an Oxygen (O2) saturation level of less than 90%, R1 would be administered O2. LPA interview with R1 at 2:00 PM revealed that R1 did not have O2 administered to R1.

(continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200519131417

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/26/2021

NARRATIVE

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(continued from LIC 9099)

LPA interview with staff at 1:25 PM however, revealed that R1 was administered O2 sometime during R1's isolation due to Covid but it was only for about two (2) hours because R1's O2 level get back to normal and the Hospice Nurse removed it.

Regarding the allegation that Residents were forced into receiving hospice services, LPA interview with the Responsible Party (RP) of R1 on 05/21/21 at 10:04 AM, revealed that it was the hospice agency staff who called the RP and suggested for R1 to be put on hospice services and not a facility staff. LPA interview with the Executive Director on 05/21/21 at 3:34 PM, also revealed that no facility staff forced any resident or family member, RP or Power of Attorney (POA) of any resident to sign up for hospice services. She added that the facility nurse could only evaluate the resident and would suggest only that hospice services may benefit the resident and it is up to the resident and their family member/RP/POA to acquire the services of a Hospice agency of their choosing with the guidance of the resident's primary care physician (PCP), as only a physician could determine whether or not a resident requires the services of a hospice agency. Moreover, LPA record review also revealed that R1, Resident #2 (R2) and Resident #3 (R3)'s Hospice agreements were all signed by their corresponding family member/RP/POA.

Regarding the allegation that facility gave false information to resident's family member, LPA record review revealed that the facility reported their first case of Covid 19 on 04/23/2020 immediately after they had learned that a resident was tested positive. Further, the facility had been in close coordination with Los Angeles County Department of Public Health (LACDPH) and the Department since the first reported case all throughout the subsequent outbreaks at the facility for guidance and technical assistance. LPA made a reasonable effort and attempted to obtain information from the Reporting Party (RP) as to who gave the false information but did not get any response from the RP.

Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2021

LIC9099 (FAS) - (06/04)

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