197608081-7-5-2023-31-AS-TAGD-CUJSMG-20230809135953

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608081
Report Date: 07/05/2023
Date Signed: 07/05/2023 02:58:45 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
06/29/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20230629152337

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:	07/05/2023
		UNANNOUNCED	TIME BEGAN:	12:26 PM
MET WITH:	Carolina Garcia-Trejo - Executive Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not issue responsible party of a refund

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced 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 12:39 PM, requested copies of facility documents relevant to the investigation at 1:02 PM and interviewed staff and Executive Director between 1:10 PM to 2:30 PM. It was alleged that the Power of Attorney (POA) of Resident #1 (R1) did not receive a refund for the unused portion of the advance payment made when R1 passed on 12/28/22. LPA's interview with R1's POA today at 12:40 PM revealed that the POA has already received the refund check about four (4) days ago with the total amount of $580.65, the amount the POA had requested. LPA's record review today at around 1:30 PM revealed that the check was sent on 07/02/23.

(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: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 31-AS-20230629152337

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: 07/05/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	(continued from LIC 9099) LPA's interview with the staff today at 2:00 PM revealed that R1's POA came to the facility to pick up R1's belongings a week after R1 passed, though most of it was donated by the POA to the facility. 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: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2