197608081-9-20-2024-31-AS-NMAN-D9GTM3-20240926145029

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608081
Report Date: 09/20/2024
Date Signed: 09/20/2024 02:30:53 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
02/12/2024 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20240212111645

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: 177	DATE:	09/20/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Joyce Martinez		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not ensure reporting requirements were followed

INVESTIGATION FINDINGS:

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At 1:30 p.m. on 09/20/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the Marketing Director and disclosed the reason for the visit.

To investigate the allegation above, LPA conducted an itnitial visit on 02/21/24 and interviewed the ED, six (06) staff members, a family member, a doctor, and hospice staff between 9:00 a.m. and 12:00 p.m., reviewed pertinent records at 2:00 p.m. including but not limited to an admission agreement, staff list, staff schedule, resident list, medication list, care notes, and care plan, and toured the facility at 3:00 p.m. Today, LPA interviewed Staff #2 (S2) telephonically at approximately 1:45 p.m.

Regarding the allegation “Staff did not ensure reporting requirements were followed” it was alleged staff did not report a cut on the arm of Resident #1 (R1) to family in April of 2023. Interview with the ED at 10:50 a.m. on 02/21/24 revealed the injury was reported to R1’s hospice agency.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

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-20240212111645

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: 09/20/2024

NARRATIVE

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Interview with Staff #1 (S1) at 11:35 a.m. on 02/21/24 revealed that the injury occurred during the night shift. S1 believed S2 reported the injury to R1’s family. Interview with S2 today revealed they reported the injury to R1's responsible party over voicemail. Record review revealed the cut was reported to R1’s hospice agency by 10:58 a.m. on 04/05/2023. The hospice order described it as a “left forearm skin tear” which was treated by an antibiotic ointment and a dressing. Based on record review and interviews, facility staff followed reporting requirements. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health and safety hazards were observed during this visit.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC9099 (FAS) - (06/04)

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