197608685-6-29-2022-31-AS-NMAN-CGNKLE-20220725075948

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608685
Report Date: 06/29/2022
Date Signed: 06/29/2022 03:26:38 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, 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 CLARITA		FACILITY NUMBER:	197608685
ADMINISTRATOR:	JOHNNY ORTIZ		FACILITY TYPE:	740
ADDRESS:	24431 LYONS AVE		TELEPHONE:	(661) 254-9933
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91321
CAPACITY:	160	CENSUS: 101	DATE:	06/29/2022
		UNANNOUNCED	TIME BEGAN:	09:48 AM
MET WITH:	Johnny Ortiz		TIME COMPLETED:	03:23 PM

ALLEGATION(S):

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Resident is not being assisted with services.
Facility did not communicate with authorized representative about change of services being provided.
Facility is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to obtain additional information for the above noted allegations. LPA met with the Executive Director (ED), Johnny Ortiz, and discussed the reason for the visit.

--- Resident is not being assisted with services.

It was alleged that resident #1 (R1) was not getting the services that the family pays for, such as diaper changing, wrapping his left leg and changing his bedding. To investigate this allegation, on 03/16/2022 at 10:15am, LPA interviewed staff and on 04/20/2022 at 3:30pm, LPA interviewed residents and conducted a physical inspection of randomly selected rooms including R1’s room. The observations and interviews revealed that the beddings were clean and, according to staff, they are changed once a week or as needed.

(CONT. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

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 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: 06/29/2022

NARRATIVE

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It was also reported that the R1’s diaper is changed at least three time per day and more if needed. On 04/20/2022 at around 4:00pm, LPA interviewed Med Tech Miriam Zepeda Aguilar. Interviews revealed that R1’s gauze is changed by home health twice a week and that the facility wraps gauze around the open wound as needed.

Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Facility did not communicate with authorized representative about change of services being provided.

It was alleged that the Responsible Party did not have any knowledge of the change in level of care. To investigate this allegation, on 03/16/2022 at 10:15am, LPA interviewed staff and requested records. On 04/20/2022 at around 5:00PM LPA interviewed the complainant. Interviews and record review revealed that an assessment was completed, the facility did notify the resident prior to the change in the level of care and the Admission Agreement, which was signed by all parties, clearly states, “…when the assessment of your needs indicates that the level of care we are providing you is not appropriate for your needs, we may change your level of care and the fees that we charge you. Any such change in fees due us resulting from a change in the level of care will be effective immediately and we will notify you or the Responsible Party of the change”.

Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Facility is in disrepair.

It was alleged that R1’s room had a leak from the room above and as current R1's ceiling is peeling and has not been repaired. To investigate this allegation, on 03/16/2022 at 10:15am, LPA interviewed staff and on 04/20/2022 at 3:30pm, LPA conducted a physical inspection of randomly selected rooms including R1’s room. Interviews revealed that one day the tenant in the room above R1’s room left the sink running and that the water was leaking below, but that it was soaked up immediately and there were no damages. During the physical inspection, LPA did not observe any disrepair in any of the rooms, including R1’s room.

(Cont. LIC 9099-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 06/29/2022

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	LPA asked the Reporting Party about the disrepair and they were unable to identify any problems or where the alleged previous problems were. The room was neat and clean, there was no sign of water damage, cracking, paint chipping or molding. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3