197608081-3-4-2022-31-AS-EMIR-CDXTJN-20220429144638

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608081
Report Date: 03/03/2022
Date Signed: 03/04/2022 10:02:06 AM

Unsubstantiated

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
02/07/2022 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20220207120245

FACILITY NAME:	AVANTGARDE SENIOR LIVING OF TARZANA		FACILITY NUMBER:	197608081
ADMINISTRATOR:	CAROLINA GARCIA-TREJO		FACILITY TYPE:	740
ADDRESS:	5645 LINDLEY AVENUE		TELEPHONE:	(818) 881-0055
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	138	CENSUS: 111	DATE:	03/03/2022
		UNANNOUNCED	TIME BEGAN:	08:41 AM
MET WITH:	Carol Trejo - Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff pushed resident while in care

Staff stole resident's personal property

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPAs met with Executive Director Carol Trejo and explained the reason for the visit.

LPAs conducted physical plant tour at 9:02 AM, requested copy of facility documents relevant to the investigation at 9:35 AM and conducted interview with additional staff and residents between 10:00 AM to 12:45 PM. Regarding the allegation that a Staff pushed resident while in care, it was alleged that Staff #1 (S1) pushed Resident #1 (R1). LPA's record review today at 9:40 AM of Police interview with R1 revealed that the alleged incident occurred on 02/04/2022 at 8:00 PM, further review revealed that S1 was not on duty at the reported time of alleged incident. LPA's interview with R1 on 02/15/22 at 11:45 AM revealed that R1 did not remember the date and time of the alleged incident. LPA's interview with Resident #2 (R2) who is the room mate of R1 also revealed that R2 did not witness any incident with S1 and R1 at anytime inside their room.
(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: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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-20220207120245

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: 03/03/2022

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Staff stole resident's personal property, it was alleged that R1 stole some money and photograph of R1's family member. LPA's interview with S1 today at 12:05 PM revealed that S1 did not take anything from R1 and was not on duty on the alleged date of the incident. LPA's record review today at 11:45 AM also confirmed that S1 was not on duty on the time of the alleged incident and further review also revealed that none of the alleged missing item is on R1's Personal property and valuables (LIC 621).

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: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

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