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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608685
Report Date: 04/07/2023
Date Signed: 04/07/2023 02:10:52 PM


Document Has Been Signed on 04/07/2023 02:10 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: 118DATE:
04/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Johnny OrtizTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director Johnny Ortiz, and Resident Services Director Venca Avivi informed them the reason of the visit. LPA conducted a case management pertaining to the a incident report that was submitted for resident # 1 (R1), and staff did not follow physician orders when administering the medication. LPA contacted the ED on 04/06/2023 to gather further information pertaining to the incident.

According to the ED and Resident Services Director Venca Avivi, R1 was scheduled to have a dental procedure and was prescribed a medication, that was to administered the day before the procedure. Staff #1 (S1) did not have accurate information on the specific date as to when the medication was supposed to be administered to R1 and was given to R1 on the wrong date. The Resident Services Director reported to LPA, the correct information was not communicated to the medication technicians. LPA determined, facility staff did not follow the correct physician orders that was provided for R1. This is a health and safety risk to residents in care.

A citation was issued during today's visit.

Exit interview, copy of report and appeal rights provided to Executive Director.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/07/2023 02:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2023
Section Cited

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Incident Medical/Dental Care. (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...facility staff..shall be permitted to assist...
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Resident Services Director reported to LPA that a medication in-service started 04/06/2023 and other dates are scheduled for additional training. LPA requested copies of the 1st training that was conducted on
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(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, staff did not administer the medication according to doctor's orders. This a health and safety risk to residents in care.
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04/06/2023. POC cleared during today's visit.

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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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
LIC809 (FAS) - (06/04)
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