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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608081
Report Date: 07/27/2022
Date Signed: 07/27/2022 01:14:21 PM


Document Has Been Signed on 07/27/2022 01:14 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: 112DATE:
07/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Alberta Cedano - Care CoordinatorTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Yelena Avetisyan and Evelin Rios conducted an unannounced Case Management-Deficiencies visit at the facility today due to deficiencies observed during the investigation of complaint control #31-AS-20220721125636.

At approximately 10:44 am while conducting a tour of the facility with Alberta Cedano Care Coordinator LPA's observed PPE cart placed near residents room. When asked Ms. Cedano confirmed that the resident in the room tested positive for COVID19. LPA's did not observe droplet precaution At approximately 11:11 am LPA Avetisyan spoke with the administrator Carolina Garcia-Trejo. Per Ms. Trejo she called the Woodland Hills Office on 7/22/2022 and reported the COVID positive, but was unable to provide the name of the staff she spoke with. LPA reminded Ms. Trejo that they need to immediately report to the department anytime they have a resident or staff who tests positive for COVID.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 809-D). Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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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Document Has Been Signed on 07/27/2022 01:14 PM - It Cannot Be Edited

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: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2022
Section Cited

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Each licensee shall furnish to the licensing agency such reports as the Department may require... (2) Occurrences, such as epidemic outbreaks ... 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 & to the local health officer
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 when appropriate. This requirement is not met as evidenced by: Based on interview & observation, the licensee did not comply with the section cited above by not reporting a resident tested positive for COVID within 24 hours which poses an immediate health, safety or personal rights risk to persons in care.
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This is a repeat violation therefore a civil penalty on the amount of $250.00 has been issued. Additional civil penalty in the amount of $100 per day will continue to accrue until a detailed/complete Plan of Correction is received. (1st citation issued 1/25/2022)

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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: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
LIC809 (FAS) - (06/04)
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