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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608081
Report Date: 11/01/2021
Date Signed: 11/01/2021 02:01:12 PM

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:ERIN MAHONEYFACILITY TYPE:
740
ADDRESS:5645 LINDLEY AVENUETELEPHONE:
(818) 881-0055
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:138CENSUS: DATE:
11/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Caroline TrejoTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced case management visit. LPA met with the administrator and explained the reason for this visit.
Upon entry to the facility a physical plant tour was conducted to ensure no immediate health and safety issues were present. During the physical plant tour no immediate health and safety issues were noted.
Facility submitted an serious incident report to licensing regarding an incident where a staff member (S1) was seen in a resident #1 (R1) room acting inappropriately. S1 was immediately escorted out of the building. Administrator conducted interviews with other staff and R1. Administrator called law enforcement, Adult Protective Services(APS), Long Term Care Ombudsman (LTCO), and R1's family and informed them about the alleged incident. LPA conducted interviews with the administrator and facility staff. LPA asked for and received copies of S1's file and R1's file. Due to the need for more information a follow up visit will be made at another time. Exit interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
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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