191592479-5-3-2022-28-AS-MVAO-CEBRB8-20220511125219

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191592479
Report Date: 04/28/2022
Date Signed: 05/03/2022 10:03:56 AM

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
08/24/2020 and conducted by Evaluator Jeremiah Randle

COMPLAINT CONTROL NUMBER: 28-AS-20200824103452

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:	01:24 PM
MET WITH:			TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Facility is obstructing resident from receiving medical care.

Facility not allowing family member to assist resident with moving.

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: Licensing Program Analyst (LPA) Tao initiated a complaint investigation for the allegations listed above on 8/24/2020. LPA Tao spoke with Administrator SUBASHSANI KUMAR, (S1) on 8/31/2020 and conducted interview. The LPA obtained copies of staff roster, resident roster, Resident #1 (R1)’s progress notes, R1’s physician report, R1’s 30-day Notice to Quit, dated 8/13/2020, and R1’s incident reports, dated 08/13/2020 and 08/24/2020. LPA Tao requested S1 to provide copies of R1’s Identification and Emergency contact information, R1’s Preplacement Appraisal, R1’s Resident Appraisal, R1’s Need and service plan, R1’s Conservatorship documents, R1’s discharge documents, and Administrator certificate. LPA Tao requested staff’s In-service training logs including Dementia, care service for mental illness residents and Medical care to elderly residents of Staff2 to Staff 6.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
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-20200824103452

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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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. The investigation consisted of the following: Interviews of staff from Staff# 2 and staff #7. 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, staff notes, Dr’s notes and copy of Conservatorship Documents.

The Investigation Revealed the Following:

Facility not allowing family member to assist resident with moving
On August 19^th 2020 LPA Tao spoke with R1, during the interview R1 stated an ambulance came to pick her up and R1 did not go with the ambulance, R1 stated that the ambulance was called by her brother R1 declined to leave and stated R1 wanted to go home with her husband, R1 did not call her brother and asked to leave. R1 also stated R1 had no concerns or complaints about staying at the facility. After the interview, the administrator stated, R1 husband died last year. R1 has dementia. LPA Tao interviewed S1, S1 stated he did not give R1 a 30 day notice but R1 responsible party gave a 30- day notice to quit 8/13/2020. S1 stated when R1 responsible party sent the ambulance to pick-up R1 to move R1 the resident refused and S1 cannot force residents. R1 also refused to go when responsible party came to pick R1 up and relocate her to another facility. S1 reported the incidents to CCL and ombudsman.
Facility is obstructing resident from receiving medical care.

On 4/25/2022 LPA Jeremiah Randle Interviewed S2 and S7. S2 provide LPA with resident notes dated 8/24/2020 that were entered by S2. The notes revealed that R1’s Responsible party called the facility and stated that R1 had a medical emergency and needed to be sent to the emergency room to be seen. S2 checked on R1 there were no visible signs or symptoms of acute distress R1 was asked if she wanted to go to the hospital to be seen R1 refused and stated R1 felt fine and wanted to be left alone. On 8/25/2020 R1 was seen by the primary care physician’s nurse practitioner which performed a weekly visit no new orders were given at that time based on review of the resident notes. On 8/27/2020 resident sustained a fall R1’s nurse practitioner was notified and instructed that the resident needed to be sent to the hospital for further evaluation R1 was sent to the hospital for treatment.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
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)

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Control Number 28-AS-20200824103452

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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On 8/28^/2020 resident was discharged from the hospital after fall and taken to a different facility per conservator’s decision. On 8/28/2020 conservator received R1’s medication and belonging. LPA Randle interviewed S7, who provided copies of the employee roster, resident room roster, R1’s residency agreement, and notice to quit from R1’s conservator. On 4/25/2022, LPA Randle interviewed R1-R4, all residents denied the allegation.

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 allegations are found to be Unsubstantiated.

Exit interview was conducted with Mildred Pascual RSD, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
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)

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