197608685-3-18-2023-31-AS-NMAN-CQJVL3-20230403163115

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608685
Report Date: 03/18/2023
Date Signed: 03/18/2023 11:19:12 AM

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
05/10/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210510084331

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: 111	DATE:	03/18/2023
		UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Venca Avivi - Resident Services Director		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Lack of Care and supervision resulting to dehydration

INVESTIGATION FINDINGS:

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This is an amendment of the report issued on 10/28/22 to change the findings.

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to deliver the findings for the above allegation. LPA met with staff Venca Avivi and explained the reason for today’s visit.

On 05/10/21, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s Investigations Branch (IB) and assigned to IB investigator Olivia Spindola.

On 05/11/2021 at 11:00 AM, LPAs Tuesday Cabiness and Rosaura Valenzuela initiated the complaint visit. LPAs Cabiness and Valenzuela conducted physical plant tour and obtained copies of the facility records relevant to the investigation. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

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-20210510084331

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: 03/18/2023

NARRATIVE

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(continued from LIC 9099)

During the course of the investigation, Investigator Spindola interviewed the Assistant Administrator, staff and family member on different dates and time from 05/13/21 to 07/17/21. IB Investigator Spindola also reviewed Hospital Records on 05/24/21 and 07/07/21 and Los Angeles Sheriff Department (LASD)’s record on 07/09/21.

Regarding the allegation that lack of care and supervision resulting to dehydration, IB Spindola’s hospital record review on 05/24/21 revealed that during these hospitalization of R1 due to fall on 03/15/21 and 04/02/21 R1 was diagnosed by the hospital with Urinary Tract Infection (UTI) and again was diagnosed with UTI on 04/30/21 when hospitalized due to another fall.

IB Investigator Spindola’s interview with staff on 05/17/21 revealed that R1 used to drink a lot of water before but since R1 declined, R1 had limited intake. LPA’s interview with three (3) care staff who used to care for R1 on 03/26/22, revealed R1 was regularly provided with liquids for hydration, including water, juice and/or soda during R1’s stay at the facility.

Based on the information gathered during the course of the investigation, there is an insufficient information to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

LIC9099 (FAS) - (06/04)

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