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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608081
Report Date: 03/25/2022
Date Signed: 03/25/2022 04:43:16 PM

Document Has Been Signed on 03/25/2022 04:43 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: 111DATE:
03/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Caroline GarciaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Wendell Smith conducted an case management visit in conjunction with a complaint visit 31-AS-20211101161122. LPA met with administrator and explained the reason for this visit.
During the course of that investigation it was found through interviews with residents and facility staff that staff # 1(S1) engaged in a sexual relationship with resident #1 (R1). On 10/29/21 S1 was observed in R1's room with their pants around their waist. S1 was immediately removed from the building. Interviews were conducted with R1 and facility staff. Los Angeles Police Department (LAPD) were notified and came to the facility. No report was taken by LAPD due to them determining the relationship was consensual. Since 10/29/21 S1 has relieved of their duties and has not been back to the facility. Deficiency cited on LIC 809 D for conduct inimical. Exit Interview conducted. Appeal Rights explained.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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 03/25/2022 04:43 PM - It Cannot Be Edited


Created By: Wendell Smith On 03/25/2022 at 03:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2022
Section Cited
CCR
87777(a)(2)

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The Department may prohibit an individual from being employed or allowed in a licensed facility as specified in Health & Safety Code Sections 1569.58 & 1569.59 (a)The department may prohibit any person from being a member of the board of directors, an executive director, a board member, or an officer of a licensee, or a licensed facility by licensee from employing, or.
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Administrator shall have an in-service with facility staff regarding proper staff-resident relationships. Copy of in-service will be sent to LPA.
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continuing the employment of, or allowing in a licensed facility, or allowing contact with clients of any employee, prospective employee, or person who is not a client who has: (2) Engaged in conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of State of CA.
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This requirement was not met as evidenced by:
Based on interviews conducted it was found that S1 engaged in a sexual relationship with R1 which posed an immediate health and safety risk to residents 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:Cassandra Harris
LICENSING EVALUATOR NAME:Wendell Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022


LIC809 (FAS) - (06/04)
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