197608685-11-17-2021-31-AS-NMAN-CBXTB5-20220224133428

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608685
Report Date: 11/17/2021
Date Signed: 11/17/2021 05:01:58 PM

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
10/20/2021 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20211020154028

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: 112	DATE:	11/17/2021
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Johnny Ortiz, Executive Director		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident sustained injury while in care.
Resident's room is not being cleaned.
Resident's hygiene needs are not being met.
Staff did not ensure that resident's room was free of hazards.

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 Johnny Ortiz, Executive Director (ED). The purpose of the visit was discussed.
--- Resident sustained injury while in care.
It was reported that the resident sustained injury while in care, staff did not ensure that resident’s room was free of hazard.

To investigate these allegations, on 10/26/2021 at 2:15pm LPA spoke to ED, the Care Staff, Med Tech and Housekeeper. Interviews revealed that Resident #1 (R1) sustained a minor cut on the index finger measuring less than one (01) cm in length, that may not be visible during hygiene assistance. The injury was self-sustained and resulted from R1 handling a broken picture frame. R1 never complained of any injuries or pain. Staff also reported that they remove any hazardous items from the room when discovered.
(Please see continuation page)

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: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

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-20211020154028

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: 11/17/2021

NARRATIVE

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--- Staff did not ensure that resident's room was free of hazards.

It was alleged that Staff did not ensure that resident's room was free of hazards. To investigate these allegations, on 10/26/2021 at 11:10am LPA spoke to facility staff. Interviews indicated that the resident’s room is cleaned daily by staff and the housekeeper deep cleans weekly. During the investigation conducted on 10/26/2021 at 11:15am the resident’s room was inspected by the LPA and the room appeared to be clean at the time of the visit. During a subsequent complaint investigation visit conducted on 11/17/2021 at 11:30am the resident’s room was again inspected by the LPA and the room appeared to be clean and free from hazard at the time of the visit. Staff also reported that they remove any hazardous items from the room when discovered.

Based on interviews, inspection and observation, there is no relevant information to support 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: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20211020154028

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: 11/17/2021

NARRATIVE

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The broken frame was stored with R1’s personal items and staff had no knowledge of it. A broken picture frame was discovered by R1’s family member who came to visit R1.

On 10/26/2021 @ 11:00am LPA Duguma inspected the room and noted that the picture frame was previously stored in a place that may not be checked by the care staff.

Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--Resident's room is not being cleaned.

It was reported that resident’s room is not being cleaned. The floor in R1’s room is sticky.

To investigate these allegations, on 10/26/2021 at 11:10am LPA spoke to facility staff including housekeepers. Interviews indicated that the room is being picked up daily as needed and deeply cleaned once a week. During the investigation conducted on 10/26/2021 at 11:00am, randomly selected rooms were inspected by the LPA which included R1’s bedroom. The floors appeared to be clean and free from hazard.

Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Resident's hygiene needs are not being met.

It was alleged that R1’s teeth were not brushed for a few days. To investigate these allegations, on 10/26/2021 at 11:30am LPA spoke to facility staff. Interviews indicated that the resident is assisted with teeth brushing and other hygiene related daily functions. During investigation conducted on 11/17/2021 @ 11:45am the resident was inspected by the LPA and the resident appeared to be clean and well-groomed.

Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

(Please see continuation page)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC9099 (FAS) - (06/04)

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