191592479-4-28-2022-28-AS-MVAO-CEBRDY-20220511125644

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191592479
Report Date: 04/28/2022
Date Signed: 04/28/2022 12:27:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2021 and conducted by Evaluator Jeremiah Randle

COMPLAINT CONTROL NUMBER: 28-AS-20211223104003

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: 47	DATE:	04/28/2022
		UNANNOUNCED	TIME BEGAN:	12:08 PM
MET WITH:	Resident Service Director Mildred Pascual		TIME COMPLETED:	12:39 PM

ALLEGATION(S):

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Resident not reimbursed as promised for services not received.

INVESTIGATION FINDINGS:

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On 04/28/22, Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced complaint visit at the above noted facility. LPA Randle met with Resident Service Director Mildred Pascual. LPA Randle explained the purpose of the visit is to deliver findings for the allegation mentioned in the complaint.

The investigation consisted of the following: This complaint was initially assigned to LPA Bonnie Tao. On 12/28/2021, LPA Bonnie Tao conducted the initial visit which consisted of interviews of Staff 1 to staff 3 and interviews of residents 2 to 6. A physical plant tour of the facility and R1’s room were conducted. R1 file review was conducted. LPA obtained a copy of resident roster, staff roster, R1's Identification and Emergency, R1’s Admission Agreement, R1’s Resident Account Summary, R1's Remittance (billing record), email printout from Staff#2 regarding credit to Jan 2022 rent.

On 4/8/2022, the complaint was reassigned to LPA Jeremiah Randle. On 4/25/2022 Licensing Program Analyst (LPA) Jeremiah Randle made an unannounced follow-up visit to the facility noted above and met with Mildred Pascual, Resident Services Director (RSD). LPA explained the reason of the visit to RSD, who assisted with the visit.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

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 28-AS-20211223104003

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ATRIA COVINA	FACILITY NUMBER: 191592479
	VISIT DATE: 04/28/2022

NARRATIVE

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LPA Randle conducted Interviews of staff from S1 and S4 and interviews of residents R7 to R10. Resident #1 (R1) file review was conducted. LPA obtained a copy of resident roster, staff roster, R1's Identification and Emergency information, R1’s Residency Agreement, fee schedule, credit addendum, resident refund request and Staff notes.

The Investigation Revealed the Following:

On 12/28/2021, LPA Bonnie Tao conducted interviews of Staff 1 to 3 which yielded the following information: S1 stated R1 was admitted to the hospital on 9/4/2021 from the facility and subsequently transferred to a rehabilitation facility. S2 was interviewed and stated that no reimbursement check was issued due to a balance remaining on January 2022 rent account that needed to be paid and R1 was still a current resident at the facility. S3 also stated if you are no longer a resident and not using service or the room only then would you be entitled to a reimbursement check. S3 stated that he did not hear the resident complaining about being unable to get a reimbursement check from the facility. LPA Jeremiah Randle met with S4 on April 25^th, 2022. S4 stated R1 overpayment of rent returned to R1 account and R1 personal effects removed April 6, 2022. S4 provided an accounting of R1’s payments and credits confirming.

On 12/28/2021, LPA Bonnie Tao conducted an observation of R1’s room and Interviews of R2 to R6. LPA Tao toured R1’s Room with S3. R1’s belongings were still in the room. LPA Tao did not observe any other resident in the room or using the room. S3 stated no other resident was using Room while R1 was in a SNF.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20211223104003

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: ATRIA COVINA	FACILITY NUMBER: 191592479
	VISIT DATE: 04/28/2022

NARRATIVE

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LPA Tao interviewed R2 through 6, those residents rendered only positive statements regarding the Facility and Staff members. Residents 2 through 6 all stated that they had no problem with finances at the facility and they had no problem with refunds or reimbursements.

LPA Jeremiah Randle met with Residents R7- R10 Residents 7 through 10 all stated “no” that they had problem with finances at the facility and they had no problem with refunds or reimbursements.

Based on LPA’s observations and interviews which were conducted, and facility records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be Unsubstantiated.

Exit interview was conducted with the Resident Service Director Mildred Pascual and a copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3