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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608081
Report Date: 05/24/2022
Date Signed: 05/24/2022 01:08:09 PM


Document Has Been Signed on 05/24/2022 01:08 PM - It Cannot Be Edited

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:CAROLINA GARCIA-TREJOFACILITY TYPE:
740
ADDRESS:5645 LINDLEY AVENUETELEPHONE:
(818) 881-0055
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:138CENSUS: 109DATE:
05/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:David AguinigaTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Michael Cava conducted a Case Management (CM) visit to facility to follow up on an incident report, alleging a possible personal rights violation involving Resident 1 (R1). During the course of the visit, interviews and record review was conducted. A physical plant inspection was also made to insure the health and safety of the residents.

Based on interviews and record review, there wasn't enough information to confirm if C1's personal rights were violated. Therefore, no citations issued at this time.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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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