197606626-7-8-2024-31-AS-EMIR-D7FP4T-20240723105940

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606626
Report Date: 07/08/2024
Date Signed: 07/08/2024 03:20:53 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/15/2024 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20240515150750

FACILITY NAME:	ARAYATA ELDERLY CARE		FACILITY NUMBER:	197606626
ADMINISTRATOR:	NATIVIDAD ARAYATA		FACILITY TYPE:	740
ADDRESS:	44849 LOTUS LANE		TELEPHONE:	(661) 948-4985
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS:	DATE:	07/08/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Natividad Arayata		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care.

INVESTIGATION FINDINGS:

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On 07/08/2024, Licensing Program Analyst (LPA) Evelin Rios conducted a subsequent unannounced complaint investigation visit. LPA met the administrator, Natividad Arayata and LPA explained the reason for the visit.

LPA toured the physical plant of the facility inside and out and did not observe any health and safety issues or concerns.

Allegation: Resident sustained an unexplained injury while in care.
It is alleged resident#1 (R1) sustained an injury in the facility which caused bleeding from nose and mouth. To investigate the allegation, an initial visit was conducted by LPAs Evelin Rios and Lorena Casillas on 05/22/24. On 05/22/24, between 2:23 p.m. and 3:00 p.m. LPAs interviewed administrator, staff present and one (1) out of four (4) residents. Between 3:00 p.m. to 3:30 p.m. LPAs reviewed and obtained copies of records relevant to the investigation. (Continue to LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

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 31-AS-20240515150750

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARAYATA ELDERLY CARE	FACILITY NUMBER: 197606626
	VISIT DATE: 07/08/2024

NARRATIVE

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On 07/08/24 LPA reviewed R1's After Visit/Discharge paperwork from their hospital stay between 05/13/24 to 5/20/24. LPA reviewed R1's medical assessment prior to admittance to this facility dated 04/26/24 and Home Health documentation dated 05/29/24. LPA also interviewed R1 who is no longer at this facility and interviewed R1's responsible person. R1 denied staff at this facility caused them to have an injury resulting in a bloody nose or mouth. R1 also stated they have occasional nose bleeds. Interview with R1's family member corroborates R1 will have nose bleeds due to nasal oxygen cannula use (a devise that delivers extra oxygen through a tube and into the nose). Review of R1's medical assessment reported, resident has a history of falling, respiratory disorders and uses an inhaler and oxygen. Interview with administrator and staff on 05/22/24 revealed R1 has a history of nose bleeds caused by oxygenation through nasal cannula. R1's discharge paperwork from 05/20/24 corroborates R1's use of oxygen and that R1 was admitted due to low oxygen and low blood pressure. According to the administrator they deny causing injury to R1. According to staff #1(S1) and administrator on the day R1 was admitted to the hospital, R1 had not experienced a fall or an injury. Furthermore, S1 states they had checked on R1 who was lying in bed. According to S1, R1 was unresponsive and S1 checked R1's vitals then called the administrator, and contacted 911. Interview with S1 reveals they did not witness R1 actively bleeding or observed dry blood around R1's nose or mouth.

Based on interviews conducted, and records reviewed there is insufficient evidence to support the allegation resident sustained an unexplained injury while in care. Therefore, the allegation is Unsubstantiated. Exit interview conducted, a copy of this report was signed and provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024

LIC9099 (FAS) - (06/04)

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