374604261-12-4-2023-08-AS-LTEZ-CYXMYR-20231228090157

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604261
Report Date: 12/04/2023
Date Signed: 12/04/2023 03:52:41 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/28/2023 and conducted by Evaluator Dawn Segura

COMPLAINT CONTROL NUMBER: 08-AS-20231128125950

FACILITY NAME:	AVANTGARDE SENIOR LIVING OF LA JOLLA		FACILITY NUMBER:	374604261
ADMINISTRATOR:	ESCOBAR, AGUSTIN		FACILITY TYPE:	740
ADDRESS:	6211 LA JOLLA HERMOSA AVE		TELEPHONE:	(818) 692-5284
CITY:	LA JOLLA	STATE: CA	ZIP CODE:	92037
CAPACITY:	45	CENSUS: 35	DATE:	12/04/2023
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Susan Caccam, Wellness Director		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee did not provide resident records to resident's authrorized representative.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to conduct an investigation into the above listed complaint allegation. LPA introduced herself, was granted entry into the facility, and met with Susan Caccam, Wellness Director, to whom LPA disclosed the reason for the visit. The facility's Regional Executive Administrator, Carolina Trejo, was contacted via telephone.

It was alleged that a former resident’s, Resident 1 (R1) [LIC 811 Confidential Names List was provided to identity the resident], family requested copies of records maintained by the facility that relate to the resident; however, the licensee has not provided the requested records.

Community Care Licensing (CCL) has investigated the above listed allegation. The investigation consisted of a tour of the facility, review of records, and interviews of facility staff. The investigation yielded that R1’s identified responsible party submitted a request, dated September 12, 2023, through a representative acting

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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 3

Control Number 08-AS-20231128125950

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AVANTGARDE SENIOR LIVING OF LA JOLLA	FACILITY NUMBER: 374604261
	VISIT DATE: 12/04/2023

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

on behalf of R1’s family, for copies of records maintained by the facility relative to R1. R1’s responsible party signed an Authorization to Release Information, dated August 30, 2023, which was submitted to the facility along with the written request for copies of R1’s records. The investigation revealed that the request was received by the facility on September 15, 2023, and the licensee was made aware at that time. As of the time of today’s visit, no evidence is maintained or has been provided to conclude that the requested records have been provided to R1’s responsible party. Accordingly, the allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D.

An exit interview was conducted with Susan Caccam, Wellness Director, and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to her at the conclusion of the visit. Susan Caccam’s signature on this report confirms receipt.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20231128125950

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AVANTGARDE SENIOR LIVING OF LA JOLLA	FACILITY NUMBER: 374604261
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/11/2023 Section Cited CCR 87506(c)(1)	1 2 3 4 5 6 7	The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated	1 2 3 4 5 6 7	Wellness Director offered to ensure that all requested records that are maintained by the facility and are responsive to the request are provided to R1's responsible party/representative by the POC due date. Proof of correction will be provided to
	8 9 10 11 12 13 14	representative. This req't was not met as evidenced by: Based on interviews and records review, licensee did not provide resident records to responsible party of 1 of 35 residents, which poses a potential personal rights risk to persons in care.	8 9 10 11 12 13 14	Community Care Licensing by the POC due date of 12/11/2023.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dawn Segura	TELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3