197608685-4-13-2022-31-AS-NMAN-CQJVL4-20230403163121

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608685
Report Date: 04/13/2022
Date Signed: 04/13/2022 02:09:26 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
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: 95	DATE:	04/13/2022
		UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Venca Avivi - Resident Care Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident's walker was in disrepair

Staff did not safeguard residents personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Resident Care Director Venca Avivi and informed the purpose of the visit.

LPA conducted physical plant tour at 9:50 AM, requested facility records relevant to the investigation at 10:30 AM and conducted interview with staff between 11:00 AM to 1:00 PM.

Regarding the allegation that resident's walker was in disrepair, it was alleged that Resident #1 (R1)'s walker leg falls off when being picked up. LPA's interview with four (4) staff on 03/26/22 between 10:00 AM to 2:00 PM and two (2) staff today between 10:00 AM to 1:00 PM revealed that no one was aware that R1's walker was broken until it was reported by R1's family member on 04/02/21. LPA's record review on 03/26/22 at around 11:30 AM also revealed that R1 had a new walker delivered the next day, 04.03/21 as ordered by the family member. (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: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

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: 04/13/2022

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that Staff did not safeguard resident's personal belongings, it was alleged that R1's eye glasses were lost. LPA's interview with Staff #1 (S1) on 03/26/22 between 10:00 AM to 2:00 PM revealed that the primary care staff of R1 reported that the R1's eye glasses broke when R1 had an unwitnessed fall on 03/15/21. LPA's interview with the Memory Care Director today at around 11:30 AM today, however, revealed that she did not receive any report about R1's broken eye glasses otherwise she should have reported it to the family member to have it replaced as it was a prescription eye glass.

Based on the information gathered during this and prior visits, there is insufficient information to support the allegation and therefore deemed unsubstantiated at this time.

Exit interview conducted. Copy of this 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: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC9099 (FAS) - (06/04)

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