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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608685
Report Date: 08/08/2022
Date Signed: 08/08/2022 03:27:37 PM


Document Has Been Signed on 08/08/2022 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CLARITAFACILITY NUMBER:
197608685
ADMINISTRATOR:JOHNNY ORTIZFACILITY TYPE:
740
ADDRESS:24431 LYONS AVETELEPHONE:
(661) 254-9933
CITY:SANTA CLARITASTATE: CAZIP CODE:
91321
CAPACITY:160CENSUS: DATE:
08/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Johnny OrtizTIME COMPLETED:
03:06 PM
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced Case Management visit to the facility. LPA arrived at 11:00 AM. Upon entry, LPA met with the Executive Director, Johnny Ortiz, and screened for COVID 19. LPA conducted a physical plant tour at 11:30 AM.

An SOC341 was received 08/02/2022 alleging that staff #1 (S1) grabbed and pulled resident #1 (R1) by the arm and wrist to re-direct the R1. Later that day, R1 complained about soreness at the site of where R1 was allegedly grabbed. On 08/08/2022, from 12:30 PM - 3:00 PM, LPA interviewed three staff and one resident. No action was taken during the visit.

No health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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