197608081-7-25-2021-31-AS-NMAN-C69UFW-20210826153324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608081
Report Date: 07/24/2021
Date Signed: 07/25/2021 12:45:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/01/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20200601091800

FACILITY NAME:	AVANTGARDE SENIOR LIVING OF TARZANA		FACILITY NUMBER:	197608081
ADMINISTRATOR:	ERIN MAHONEY		FACILITY TYPE:	740
ADDRESS:	5645 LINDLEY AVENUE		TELEPHONE:	(818) 881-0055
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	138	CENSUS: 103	DATE:	07/24/2021
		UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Jero Argota - Assistant Care Coordinator		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not give resident a sufficient amount of water

Staff handled resident in a rough manner

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit to this facility to further investigate the above stated allegations. LPA met with Assistant Care Coordinator Jero Argota and explained the reason for the visit. LPA also talked to the new Executive Director Carolina Garcia Trejo on the phone and designated Mr. Argota to sign the report.

At around 9:00 AM, LPA conducted physical plant tour. At 10:00 AM, LPA requested copy of pertinent facility documents relevant to the investigation. At 11:02 AM to 2:30 PM, LPA conducted interview with staff and residents. Regarding the allegation that Staff did not give resident a sufficient amount of water, LPA interview with five (5) Memory Care Unit staff today between 11:02 to 2:30 PM revealed that staff conduct routine check to ensure that all residents are comfortable and their needs are met. LPA interview with staff present during the incident on 05/22/2020 where Resident #1 (R1) was screaming for water, revealed that R1 had just had dinner and had water and juice on R1's bedside. LPA record review today at 2:35 PM revealed that R1 had a diagnosis or Dementia and confusion. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2021

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-20200601091800

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 TARZANA	FACILITY NUMBER: 197608081
	VISIT DATE: 07/24/2021

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 interview with Resident #2 (R2) also revealed that staff always provide R2 water whenever R2 asked for it. Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.

Regarding the allegation that Staff handled resident in a rough manner, LPA interview with five (5) memory care staff between 11:02 AM to 2:34 PM, revealed that no one witnessed any staff mistreating and/or rough handing any resident at any time and LPA interview with staff present during the incident on 05/22/2020, denied rough handling or mistreating R1 in anyway.

Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2