<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608685
Report Date: 05/24/2022
Date Signed: 05/24/2022 03:21:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/15/2022 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20220315143212
FACILITY NAME:ATRIA SANTA CLARITAFACILITY NUMBER:
197608685
ADMINISTRATOR:JOHNNY ORTIZFACILITY TYPE:
740
ADDRESS:24431 LYONS AVETELEPHONE:
(661) 254-9933
CITY:SANTA CLARITASTATE: CAZIP CODE:
91321
CAPACITY:160CENSUS: 101DATE:
05/24/2022
UNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Venca AviviTIME COMPLETED:
03:19 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not providing resident’s medications as prescribed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to obtain additional information for the above noted allegation. LPA met with Venca Avivi and discussed the reason for the visit.

--- Staff not providing resident’s medications as prescribed.

It was alleged that the Resident #1 (R1) was given his potassium pills twice a day instead of once a day as written on the bottle. To investigate this allegation, on 03/16/2022 at 11:50am, Licensing Program Analysts (LPA) requested pertinent documents and, on 04/20/2022 at 3:45pm, LPA interviewed staff and complainant. A review of R1’s Physician’s Orders revealed that R1 was prescribed potassium 10mg once daily, yet the Medication Administration Records (MAR) dated 08/20/2020 shows that the facility administered the medication twice daily.
(Cont. on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
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 4
Control Number 31-AS-20220315143212
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ATRIA SANTA CLARITA
FACILITY NUMBER: 197608685
VISIT DATE: 05/24/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on the information gathered during the course of this investigation, the allegation is SUBSTANTIATED at this time.

No other health and safety hazards were noted during the visit. An exit interview was conducted. A copy of this report, the original LIC 9099-D and Appeal Rights were discussed and provided. The signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20220315143212
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA SANTA CLARITA
FACILITY NUMBER: 197608685
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2022
Section Cited
CCR
87465(a)(1)
1
2
3
4
5
6
7
87465(a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will schedule medication training for all staff with an approved vendor. Training will need to be scheduled within 24 hours and completed by 6/07/2022. Administrator will provide a copy of the scheduled training to the LPA after scheduling.
8
9
10
11
12
13
14
Based on medication review, the licensee did not comply with the section cited above as the facility did not ensure that medications were given as prescribed which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4