191592479-6-9-2021-28-AS-FFIS-CKMVQP-20221028163840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191592479
Report Date: 06/09/2021
Date Signed: 06/09/2021 05:14:28 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, 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
06/04/2021 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20210604121329

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: 48	DATE:	06/09/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	SUBASHSANI KUMAR, administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not ensure that resident received adequate medical attention.

Staff did not address resident's change in condition.

Facility is dirty.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted an initial 10-Day complaint investigation regarding the above allegations. LPA discussed the purpose of the visit with Administrator at the facility.
The investigation consisted of the following: LPA interviewed from Staff #1 to #4 including Administrator; interviews with residents from Resident #1 to Resident #5; reviewed R#6’s incident report, R#6’s death report, Resident #6’s files, Staff’s in-service-training log, and cleaning log; and obtained Resident roster and Staff roster.

For the allegation of Staff did not ensure that resident received adequate medical attention:
Based on observations and interviews conducted during today’s visit, the findings indicate residents and staff reported that staff ensured adequate medical attention to resident was provided. Four (4) out of four (4) staff and five (5) out of five (5) residents reported that staff ensured medical attention is provided to all residents. Five (5) out of five (5) residents stated that they received medical attention when needed and they were not aware of any resident that their medical attention was not ensured properly. Thus, the investigation revealed that resident received adequate medical attention. (- continued in LIC 9099C-)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

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-20210604121329

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: 06/09/2021

NARRATIVE

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For the allegation of Staff did not address resident's change in condition:
Based on observations and interviews conducted during today’s visit, the findings indicate residents and staff revealed that staff would report resident’s change of condition timely. Four (4) out of four (4) staff and five (5) out of five (5) residents reported that staff would address resident’s condition if there are any changes. Review of staff training record showed that staff were trained to address the resident’s situation and ensure providing medical attention timely. Five (5) out of five (5) residents stated that they were not aware of any residents who had changed in condition but was not addressed by staff. Therefore, the investigation revealed that Staff did address resident's change in condition.

For the allegation of Facility is dirty:
Based on observations and interviews conducted during today’s visit, the findings indicate residents and staff reported that facility is clean and in good repair. Four (4) out of four (4) staff and five (5) out of five (5) residents reported that the facility was cleaned on regularly. All five residents indicated their rooms were clean at least once a week or more if needed. From the facility tour, LPA observed the facility and rooms are clean and in good repaired. Thus, the investigation revealed that the facility is clean.

Based upon physical plant observation, interviews conducted, and documents reviewed, the findings indicate although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated.

A telephonic exit interview was conducted with assistant Administrator. A hard copy of the report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

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