197608081-5-25-2023-31-AS-TAGD-CUBMSX-20230802095239

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608081
Report Date: 05/25/2023
Date Signed: 05/25/2023 02:29:58 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
05/23/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20230523110505

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: 137	DATE:	05/25/2023
		UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Carolina Garcia - Trejo - ED		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff are not following the admission agreement

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Executive Director Carolina Garcia-Trejo and explained the reason for the visit.

LPA conducted physical plant tour at 9:50 AM, requested copies of facility documents relevant to the investigation at 10:15 AM and interviewed staff between 11:00 AM to 12:00 PM. LPA also conducted records review between 12:00 PM and 1:30 PM and requested additional documents.

It was alleged that the facility did not reimburse Resident #1 (R1)'s community fee in accordance with the facility's admission agreement. LPA's record review today between 12:00 PM and 1:30 PM revealed that the facility sent the refund check to R1's Power of Attorney (POA) on 05/10/23 with amount of $2100.00 representing 60% of pro rated refund for the Community Fee per the admission agreement. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230523110505

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AVANTGARDE SENIOR LIVING OF TARZANA	FACILITY NUMBER: 197608081
	VISIT DATE: 05/25/2023

NARRATIVE

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(continued from LIC 9099)

Admission agreement states that:

" A Refund of 60 percent of the preadmission fee in excess of $500 shall be provided if the resident leaves for any reason during the second month of residency."

LPA's further record review also revealed that R1 was admitted on 12/08/22 and moved on to another facility on 01/17/23 from the hospital. LPA's interview with the administrator today at 11:00 AM revealed that the administrator instructed the facility's accountant to send the check to R1's POA and was told that the accountant sent the check on 05/10/23, the accountant however, quit on 05/12/23 but LPA was able to obtain a copy of the check sent.

Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC9099 (FAS) - (06/04)

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