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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608081
Report Date: 06/26/2023
Date Signed: 06/26/2023 03:08:21 PM


Document Has Been Signed on 06/26/2023 03:08 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: 137DATE:
06/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Carolina Garcia-TrejoTIME COMPLETED:
03:18 PM
NARRATIVE
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Licensing Program Analyst (LPA), Tihesha Smith conducted a Case Management visit in conjunction with complaint (31-AS-20230622091845) and met with staff.

LPA Smith observed staff setting up/preparing meals in courtyard. LPA discussing with staff #1 and staff #2 revealed that kitchen plumbing was repaired. LPA interview with Administrator revealed that the incident was not reported to the Community Care Licensing Department (CCLD). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. Occurrences, such as epidemic outbreaks, poisonings, catastrophes, or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours.

LPA informed the Administrator that all staff members are mandated reporters and are all responsible for reporting.

During today’s visit, the Administrator provided a copy of the 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.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2023
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 06/26/2023 03:08 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: 06/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2023
Section Cited
CCR
87211(a)(2)

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 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, …. or major accidents which threaten the welfare, safety or health of residents, … shall be reported within 24 hours either by telephone or facsimile to the licensing agency.
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Lincensee/Administrator shall ensure a written report is submitted to the licensing agency and provide signed and dated statement noting understanding of Reporting Requirements to LPA by POC date:06/30/23
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Based on interview, administrator revealed she failed to notify the department, regarding the kitchen plumbing incident that occurred on 05/26/23, which poses a potential health and safety risk to persons in care.
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LIC 624 faxed and copy received at time of visit. Statement pending.

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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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2023
LIC809 (FAS) - (06/04)
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