191592479-11-17-2021-28-AS-WSHO-C9PW4K-20211214155740

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191592479
Report Date: 11/17/2021
Date Signed: 11/17/2021 02:08:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/26/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211026095507

FACILITY NAME:	ATRIA COVINA		FACILITY NUMBER:	191592479
ADMINISTRATOR:	SUBASHSANI KUMAR		FACILITY TYPE:	740
ADDRESS:	825 W SAN BERNARDINO RD		TELEPHONE:	(626) 967-9621
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY:	90	CENSUS: 50	DATE:	11/17/2021
		UNANNOUNCED	TIME BEGAN:	01:17 PM
MET WITH:	Administrator, Irina Sarkisyan		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Resident was sexually abused while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint investigation for the allegation listed above. LPA met with Aministrator, Irina Sarkisyan and explained the reason for the visit. The initial complaint visit was conducted on 10/27/21.

The investigation consisted of the following: During the initial visit the facility was toured including the first and second floor, dining room and activity room. Interviews were conducted with three staff and four residents. Resident #1's (R1) file was reviewed and LPA obtained copies of R1's physician's report, assessment, and incident report. A staff schedule was also obtained. An additional staff member was interviewed on 11/1/21. Interview was also conducted with an urgent care nurse.

The investigation revealed the following: It's alleged R1 was assaulted by an unknown individual on Sunday 10/17/21 at 1 am while taking a shower. Facility staff were made aware of the allegation on 10/22/21. As a result the facility called 911 and paramedics. Covina Police Department responded and interviewed R1 and faciltiy staff. Continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20211026095507

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ATRIA COVINA	FACILITY NUMBER: 191592479
	VISIT DATE: 11/17/2021

NARRATIVE

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R1 was not transported to the hospital due to not having any injuries and was not in distress. Facility reported the incident to R1's family and Community Care Licensing. Facility also scheduled an appointment with R1's physician for an evaluation.

R1 was interviewed and R1 could not provide any details of the alleged incident and indicated that maybe it didn't happen. R1 indicated that he/she didn't have any injuries and indicated he/she feels safe in the facility. Other residents interviewed indicated the facility is safe and no one has mentioned being mistreated. Staff were interviewed including the two staff working the night of the alleged incident. Staff #1 (S1) confirmed R1 called S1 to his/her room at approximately 1:00 am to report water on the bathroom floor. S1 indicated that R1 was "normal" and not in distress. S1 cleaned the area and exited the room. Interview conducted with urgent care nurse revealed R1 was examined on 10/22/21. R1 did not have any injuries that would suggest sexual assault. Facility was toured and there were no cameras seen inside the facility. There were no witnesses or documentation to confirm the alleged incident occurred.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview held and a copy of the report was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC9099 (FAS) - (06/04)

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