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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608081
Report Date: 06/23/2023
Date Signed: 06/23/2023 04:03:53 PM


Document Has Been Signed on 06/23/2023 04:03 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
N LA & CEN COA AC/SC, 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: 136DATE:
06/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carolina Trejo- AdministratorTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Mariana Agban and Angela Panushkina, conducted a CASE MANAGEMENT visit in conjunction with a complaint (#31-AS-20230615153708) and met with the Administrator. LPAs explained the reason for the visit.

LPAs were informed that on 11/04/22 R1 checked self into Skilled Nursing Facility (SNF) and the incident was not submitted to the Community Care Licensing Department (CCLD) in a timely manner. Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting.

During today’s visit, the Administrator provided a copy of a written Incident Report.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D.

Exit interview conducted, appeal rights and copy of report given emailed to the Executive Director.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/23/2023 04:03 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
N LA & CEN COA AC/SC, 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: 06/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
87211(a)(1)A,B&D

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Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in A, B & D...
This requirement is not met as evidenced by:
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Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copy of the training materials and certificates, for all staff members, shall be submitted to LPA by POC date.
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Based on interviews and record reviews, conducted by LPAs during todays visit, the licensee did not comply with the section cited above by failing to notify CCLD regarding the incidents that occurred on 11/04/22 with R1, which poses a potential health and safety risk to persons in care.
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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: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
LIC809 (FAS) - (06/04)
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