191592479-9-29-2022-28-AS-FFIS-CKMVQM-20221028163834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191592479
Report Date: 09/29/2022
Date Signed: 09/29/2022 04:40:18 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: 57	DATE:	09/29/2022
		UNANNOUNCED	TIME BEGAN:	02:02 PM
MET WITH:	Alondra Fuentes, administrator		TIME COMPLETED:	04:50 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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***This report serves as an amendment and supersedes the original complaint investigation report created on 06/09/21. The purpose of this amended Licensing report is to provide clarification of the original complaint. The findings remain substantiated. ***

On 06/09/21, Licensing Program Analyst (LPA) Tao conducted an unannounced initial 10 days complaint investigation and addressed the above allegations. LPA met with the previous Administrator, Subashsani Kumar. Today 09/29/22, Licensing Program Analyst (LPA) Tao conducted a subsequent complaint investigation visit and addressed the above allegations to the current administrator, Alondra Fuentes.

The investigation consisted of the following: LPA interviewed staff from staff #1 (S1) to staff#6 (S6) and interviews residents from resident #1 (R1) to resident #5 (R5). LPA reviewed and obtained resident#6 (R6)’s incident report, R6’s death report, R6’s facility files, staff’s in-service-training log, cleaning log, resident roster and staff roster. (-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: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

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: 09/29/2022

NARRATIVE

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The investigation revealed the following:

In regard to allegation that “staff did not ensure that resident received adequate medical attention,” it is alleged that facility did not provide medical attention to R6 properly. Six (6) out of six (6) staff and five (5) out of five (5) residents reported that staff ensured medical attention is provided to residents on a timely basis. All five 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. Interview with staff indicated nurse practitioner would visit R6 at least once a week and provide medical care to R6 in addition to the facility staff’s care. LPA toured R6’s room and tested the room's call button. Staff responded to the call immediately and came to R6’s room in ~5 minutes. Based on observations and interviews conducted, staff would ensure providing adequate medical attention to resident and residents received adequate medical attention.

In regard to allegation that “staff did not address resident's change in condition”, it is alleged that facility did not address R6’s change of condition on a timely basis. Six (6) out of six (6) staff and five (5) out of five (5) residents reported that staff would address resident’s condition if residents have any changes of conditions. Review of staff training record showed that staff were trained to address the resident’s change of condition 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. Staff interviews revealed that medical attention is provided to residents and notified residents’ primary physicians timely. As mentioned above, staff interview indicated nurse practitioner had provided medical care to R6 timely. Based on observations and interviews conducted, the findings indicated staff would report resident’s change of condition timely.

In regard to allegation that “facility is dirty”, it is alleged that R6’s room is dirty. Five (5) out of six (6) staff and five (5) out of five (5) residents reported that facility and residents’ room were cleaned on a regular basis. One (1) out of five (5) staff could not corroborate the allegation. Interview of resident addressed that their rooms were clean at least once a week or more if needed. Interviews of staff, including housekeepers, indicated that residents’ room were cleaned at least once a week. From the facility tour, LPA observed the facility and rooms, including R6’s room, were clean, no stain on carpet and in good repair. Based on observations and interviews conducted, the findings indicate facility and residents rooms are clean and in good repair. Thus, the investigation revealed that the facility is clean. (-continued in LIC 9099C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

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: 09/29/2022

NARRATIVE

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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.

An exit interview was conducted with administrator, Alondra Fuentes. 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: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC9099 (FAS) - (06/04)

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