AVANTGARDE SENIOR LIVING OF TARZANA

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes... the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above by not notifying the physician of Resident #1 (R1) after after their change of condition which posed a potential risk to the Health, Safety, or Personal Rights of persons in care.

Official plan of correction

Licensee to conduct an in-service training on the cited section and submit proof by the POC due date.

Deadline recorded: Mar 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.312(a)

Regulation authority

HSC

What the official deficiency says

§1569.312 Basic services requirements - Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not providing adequate supervision to Resident #1 (R1) which posed an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Licensee will conduct an in-service training on the cited section and submit to Licensing by the plan of correction due date.

Deadline recorded: Dec 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, …. or major accidents which threaten the welfare, safety or health of residents, … shall be reported within 24 hours either by telephone or facsimile to the licensing agency. Based on interview, administrator revealed she failed to notify the department, regarding the kitchen plumbing incident that occurred on 05/26/23, which poses a potential health and safety risk to persons in care.

Official plan of correction

Lincensee/Administrator shall ensure a written report is submitted to the licensing agency and provide signed and dated statement noting understanding of Reporting Requirements to LPA by POC date:06/30/23 LIC 624 faxed and copy received at time of visit. Statement pending.

Deadline recorded: Jun 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in A, B & D... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPAs during todays visit, the licensee did not comply with the section cited above by failing to notify CCLD regarding the incidents that occurred on 11/04/22 with R1, which poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copy of the training materials and certificates, for all staff members, shall be submitted to LPA by POC date.

Deadline recorded: Jun 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

(a)...Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation... Based on LPA's interviews and record review, the licensee failed to ensure that the resident’s personal rights were observed and respected by the previous administrator. This poses an immediate safety and personal rights risk to the resident in care.

Official plan of correction

Facility terminated the previous administrator and cleared overdue balances from residents identified to have been in collections by previous administrator's actions. No POC required at this time.

Deadline recorded: Jan 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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 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.

Deadline recorded: Aug 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87470(c)(1)

Regulation authority

CCR

What the official deficiency says

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. 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.

Official plan of correction

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 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.

Deadline recorded: Aug 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(5)(A)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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. Licensee/administrator will submit copies of the updated records for the 7 residents as POC.

Deadline recorded: Aug 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87633(b)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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 Title 22 are documented on the care plans. .

Deadline recorded: Aug 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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.

Deadline recorded: Aug 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

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. This requirement is not met as evidenced by: 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.

Official plan of correction

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.

Deadline recorded: Aug 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

Each licensee shall furnish to the licensing agency such reports as the Department may require... (2) Occurrences, such as epidemic outbreaks ... which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency & to the local health officer when appropriate. This requirement is not met as evidenced by: Based on interview & observation, the licensee did not comply with the section cited above by not reporting a resident tested positive for COVID within 24 hours which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator and all support staff will attend 2 hours vendorized training regarding the cited section. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 7/28/2022 and completion of training by 8/12/2022. This is a repeat violation therefore a civil penalty on the amount of $250.00 has been issued. Additional civil penalty in the amount of $100 per day will continue to accrue until a detailed/complete Plan of Correction is received. (1st citation issued 1/25/2022)

Deadline recorded: Jul 28, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

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: Based on observations made during the 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.

Official plan of correction

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 scheduled training dates by 7/28/2022 and completion of training by 8/12/2022. 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.

Deadline recorded: Jul 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87470(c)(1)

Regulation authority

CCR

What the official deficiency says

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. Based on observations made 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.

Official plan of correction

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 scheduled training dates by 7/28/2022 and completion of training by 8/12/2022. 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.

Deadline recorded: Jul 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87777(a)(2)

Regulation authority

CCR

What the official deficiency says

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. 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.

Official plan of correction

Administrator shall have an in-service with facility staff regarding proper staff-resident relationships. Copy of in-service will be sent to LPA. 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.

Deadline recorded: Mar 28, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

FIRE CLEARANCE. All facilities shall maintain a fire clearance. Prior to accepting persons over 60 years of age none ambulatory and/or bedridden the licensee shall notify the licensing agency and obtain an appropriate fire clearance. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above retaining 4 bedridden residents in rooms that do not have bedridden fire clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/26/2022 Plan of Correction Licensee/Administrator will notify the Department how they will correct the cited deficiency. Licensee/Administrator can submit an LIC 200 and facility sketch to identify additional rooms they would like to obtain bedridden fire clearance or move the identified residents to proper fire cleared room. This is a zero tolerance violation therefore civil penalty in the amount of $500 has been issued. Civil penalties in the amount of $100 dollars per day will accrue until POC is completed.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

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: Deficient Practice Statement Based on 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.

Official plan of correction

POC Due Date: 01/27/2022 Plan of Correction 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.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

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. This requirement is not met as evidenced by: Deficient Practice Statement Based on 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.

Official plan of correction

POC Due Date: 02/04/2022 Plan of Correction 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.

Official classification

Type B

Official code

87705(c)(5)(A)

Regulation authority

CCR

What the official deficiency says

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: Deficient Practice Statement Based on 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.

Official plan of correction

POC Due Date: 02/04/2022 Plan of Correction 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. Licensee/administrator will submit the names of the residents, room numbers and dates the updated physicians reports were obtained and re-appraisals completed.

Official classification

Type A

Official code

87633(b)

Regulation authority

CCR

What the official deficiency says

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: Deficient Practice Statement Based on 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.

Official plan of correction

POC Due Date: 01/27/2022 Plan of Correction 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 Title 22 are documented on the care plans. .

Official classification

Type A

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above by not properly notifying the department when 2 residents tested positive for COVID-19. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/26/2022 Plan of Correction Licensee/Administrator will notify the department in writing what steps will be taken to prevent a repeat violation of this regulation.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not ensuring staff receive required annual training as it relates to their job duties which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/04/2022 Plan of Correction Licensee/Administrator will schedule required training including first aid/CPR for all staff. Verification of staff training with the trainers credentials, copies of training materials will need to be submitted as POC.

Official classification

Type B

Official code

87412(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (A) Trainer’s full name; (B) Subject(s) covered in the training; (C) Date(s) of attendance; and (D) Number of training hours per subject. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not properly documenting staff training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/26/2022 Plan of Correction Licensee/Administrator will review the regulation and submit a written statement indicate that they understand and will ensure to properly document staff training at all times.

Official classification

Type B

Official code

87411(d)(5)

Regulation authority

CCR

What the official deficiency says

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above by not ensuring staff received training on infection prevention, symptoms, transmission and PPE use by an individual trained in infection control and not ensuring staff are fit tested for N95 masks as required and indicated in the licensees mitigation plan which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/27/2022 Plan of Correction Licensee/Administrator will schedule training for all staff to be provided by an individual trained in infection control and schedule all staff to be fit tested for N95 masks. Verification of the scheduled training with the trainers credentials nd lwill need to be submitted by 1/27/2022 and verififcation of compeleted training will need to be completed by 2/3/2022.Fit testing will also need to be scheduled by 1/27/2022 urs and completed by 2/3/2022 days. Licensee/Administrator will email LPA with the scheduled testing dates and locations for all staff and submit documentation once fit testing is completed.