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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608081
Report Date: 08/09/2022
Date Signed: 08/09/2022 02:26:42 PM

Document Has Been Signed on 08/09/2022 02:26 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: 110DATE:
08/09/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Joyce Martinez - Marketing DirectorTIME COMPLETED:
02:40 PM
NARRATIVE
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An unannounced Plan of Correction (POC) visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. The purpose of this visit is to follow up on the pending Plan of Corrections (POCs) that were issued during a required annual visit conducted on 01/25/2022 by LPA Avetisyan, Additional citations were issued on 7/27/2022 during a Complaint investigation and Case Management visit.

On 1/26/2022 Licensee/Administrator were cited for the following, and complete plan of corrections were not submitted. On 1/26/2022 Administrator faxed LPA written statements however the written statement did not have the information as discussed and documented on the Annual Report.
  • 87608 (a)(5)(B) and 87608 (a)(3) Postural Supports :
  • 87705 (c)(5)(A) Care of Persons with Dementia.
  • 87633 (b) Hospice Care of Terminally Ill Residents
  • 1569.625 (b)(2) Staff Training
  • 87412 (c)(2) Personnel Records.


ON 7/27/2022 Licensee/Administrator were cited for the following. As of Todays visit Plan of Corrections have not been submitted.
  • 87468.1 (a)(2) Personal Rights of Residents in all facilities.
  • 87470 (c)(1) Infection Control Requirements
  • 87211 (a)(2) Reporting Requirements. - This deficiency was a repeat citation therefore civil penalty in the
amount of $250.00 was issued. Administrator was informed that additional civil penalty in the amount of $100 per day would continue to accrue until a detailed/complete Plan of Correction was submitted to the Department.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/09/2022
NARRATIVE
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The licensing report also gave notice that failure to correct the violation between a specified length of time would result in the issuance of additional civil penalties. Because the licensee/administrator failed to make the corrections additional civil penalty of $100 dollars per day has been issued in the amount of $1300.99 (7/28/2022 to 8/9/2022). Additional civil penalties in the amount of $100 per day will continue to accrue until Plan of Correction is submitted.

During today's visit the licensee/Administrator were re-cited for the plan of corrections that were not submitted.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 809-D). Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/09/2022 02:26 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 08/09/2022 at 01:36 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: 08/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/10/2022
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities(a)...(2) To be accorded safe, healthful... accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Licensee/Administrator and all staff will attend infection control training to be provided by an individual trained/certified in infection control. Administrator will designate staff to screen all visitors for Covid-19 upon arrival. Licensee/administrator will submit the credentials of the trainer with the
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Based on observations made during the 7/27/2022 complaint investigation visit the staff did not comply with the section cited above by not wearing face mask/covering while working in the facility which poses a potential health, safety and personal rights risk to residents in care.
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scheduled training dates by 8/10/2022 and completion of training by 8/15/2022. Additionally administrator will submit a signed dated written statement notifying the department what steps will be taken to ensure staff are wearing masks appropriately at all times while working.
Type A
08/10/2022
Section Cited
CCR87470(c)(1)

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87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance.
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Licensee/Administrator and all staff will attend infection control training to be provided by an individual trained/certified in infection control. Administrator will designate staff to screen all visitors for Covid-19 upon arrival. Licensee/administrator will submit the credentials of the trainer with the
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Based on observations made during the 7/27/2022 Complaint Investigation the licensee/administrator did not comply with the cited section by not ensuring staff are following infection control Requirements which poses an immediate Health and Safety and personal rights risk to persons in care.
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scheduled training dates by 8/10/2022 and completion of training by 8/15/2022. Additionally administrator will submit a signed dated written statement notifying the department what steps will be taken to ensure staff are wearing masks appropriately at all times while working.
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:Eva Miller
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022


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Document Has Been Signed on 08/09/2022 02:26 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 08/09/2022 at 12:54 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: 08/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2022
Section Cited
CCR
87705(c)(5)(A)

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Licensees who accept & retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment, & a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
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Licensee/Administrator will review files for all residents diagnosed with dementia and identify those residents who need a current medical assessment and reappraisal. Licensee/Administrator will obtain the required records.
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Based on the 1/25/2022 Annual Visit record review, the licensee did not comply with the section cited above by not ensuring 7 out of 7 residents diagnosed with Dementia had an annual medical assessment and reappraisal which poses a potential health, safety or personal rights risk to persons in care.
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Licensee/administrator will submit copies of the updated records for the 7 residents as POC.
Type A
08/12/2022
Section Cited
CCR87633(b)

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A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following

This requirement is not met as evidenced by:
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Licensee/Administrator will review the regulation and records for all 22 residents. Administrator will obtain current, complete hospice care plans for all residents. Administrator will submit the names of all the hospice residents, room numbers and indicate the date the hospice care plans were obtained and indicate that all information required by
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Based on the 1/25/2022 Annual Visit record review, the licensee did not comply with the section cited above by not retaining current complete hospice care plan as required by title 22 for 7 out of 7 residents which poses an immediate health, safety or personal rights risk to persons in care.
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Title 22 are documented on the care plans. .
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:Eva Miller
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/09/2022 02:26 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 08/09/2022 at 12:40 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: 08/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2022
Section Cited
CCR
87608(a)(5)(B)

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Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
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Licensee/administrator will tour rooms for all hospice residents and identify those who are utilizing full and/or half bed rails. Licensee/Administrator will contact the hospice agencies and obtain current hospice care plans which indicate the need for the full rails or order for half rails. Copies of the hospice care plans will need to be submitted as POC.
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Based on the 1/25/2022 Annual Visit observation and record review the licensee did not comply with the section cited above by utilizing full bed rails for hospice residents without obtaining a hospice care plan that indicates the need for the full rails which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
08/12/2022
Section Cited
CCR87608(a)(3)

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Postural Supports. A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. The licensing agency is authorized to require additional documentation if needed.

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Licensee/administrator will tour rooms for all residents and identify those who are utilizing bed rails. Licensee/Administrator will contact the physicians and obtain order for postural support for those identified as not having one. Administrator will submit the names of the residents room numbers and dates the orders were obtained as POC.
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Based on the 1/25/2022 Annual Visit observation and record review the licensee did not comply with the section cited above by utilizing half bed rails for 6 residents without a written order from the physician which poses a potential health, safety or personal rights risk to persons 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:Eva Miller
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022


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