197608081-4-26-2022-31-AS-EMIR-CEBRJC-20220511130343

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608081
Report Date: 04/26/2022
Date Signed: 04/26/2022 02:41:22 PM

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
04/22/2022 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20220422121241

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: 109	DATE:	04/26/2022
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Carolina Garcia-Trejo		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide medical attention for resident in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegation. It's being reported that Resident 1 (R1) complained of shortness of breath, but was refused immediate medical attention. LPA Cava met with the administrator, Carolina Garcia-Trejo, and advised her of the allegation. During the course of the investigation, a physical plant inspection, interviews and record review was made.

Per interviews with the administrator and staff, R1 had only lived in the facility for two weeks. Since admission, R1 has been aggressive towards staff and had made some false allegations. Regarding the allegation of not being provided immediate medical attention, administrator and staff denies them. Staff stated in the early morning of 4/21/22, on or around 4am, R1 never informed the NOC shift he was experiencing pain. R1 carries a personal cell phone and called 911 on his own to get transported to the hospital. R1 was admitted for treatment, and then transfered to a skilled nursing facility. It is unknown

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 31-AS-20220422121241

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: 04/26/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

if R1 will return back to Avantgarde. R1 will continue to receive treatment and hospice care at the skilled nursing facility at this time.

According to R1's relative/responsible person (RRP), she is involved directly with R1's care. She is aware that R1 was experiencing pain on 4/21/22, and that R1 called 911 in the early morning on his own. Facility staff was made aware of this. RRP had no complaints or concerns of the incident or on what had occurred, and also denies the allegation of staff not providing medical attention for resident in care.

Based on the information obtained, there wasn't enough evidence to prove the allegation of staff not providing medical attention for resident in care. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2