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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608685
Report Date: 10/28/2022
Date Signed: 04/11/2023 08:08:28 AM

Substantiated


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 CLARITAFACILITY NUMBER:
197608685
ADMINISTRATOR:JOHNNY ORTIZFACILITY TYPE:
740
ADDRESS:24431 LYONS AVETELEPHONE:
(661) 254-9933
CITY:SANTA CLARITASTATE: CAZIP CODE:
91321
CAPACITY:160CENSUS: 109DATE:
10/28/2022
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Venca Avivi - Resident Care DirectorTIME COMPLETED:
01:11 PM
ALLEGATION(S):
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Lack of Care and supervision resulting to multiple falls sustaining severe injuries

Due to insufficient staffing residents needs were not met
INVESTIGATION FINDINGS:
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This is an amendment of the report issued on 10/28/22 to partially 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)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
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: 10/28/2022
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 multiple falls sustaining severe injuries, it was alleged that Resident #1 (R1) had fallen four (4) times between the period of 12/07/20 to 04/02/21 resulting to multiple injuries. IB Investigator Spindola’s interview with four (4) staff on 5/27/21, 07/08/21 and 07/14/21 revealed that two (2) out of four (4) staff believed that they were unable to help residents at the memory care unit as they should be, due to lack of staff. LPA’s record review on 10/20/22 at around 1:45 PM revealed that the last Functional Needs Assessment and Functional Needs and Services Plan for R1 was done on 03/25/21. The need of assistance on the document was scored by the points. R1 was a fall risk resident and required “stand-by/remind” assistance 3 x per day and escort assistance as needed but scored “0” on the assessment. On the status check also R1 required “stand-by/remind” assistance 3x a day but scored “11” on the assessment. IB Investigator’s interview with Staff #1 (S1) on 07/14/21 at 2:30 PM, revealed that on 04/30/21 S1 saw R1 on the hallway but was unable to help R1 because S1 was assisting another resident. By the time S1 rushed to assist R1, resident was found on the floor. Investigator Spindola’s interview with Staff #2 (S2) on 5/17/21 at 12:30 PM also revealed that R1 fell twice on 04/30/21 between 8:00 AM to 9:00 on the first fall and at 11:15 AM, R1 was hospitalized on the 2nd fall, and no one witnessed R1 falling on both incidents.

Regarding the allegation that due to insufficient staffing residents needs were not met, it was alleged that the memory care unit was understaffed. IB Investigator Spindola’s interview with four (4) staff on 5/27/21, 07/08/21 and 07/14/21 revealed that two (2) out of four (4) staff believed that they were unable to help residents at the memory care unit as they should be due to lack of staff. LPA's interview with four (4) staff on 03/26/22 between 10:00 AM to 2:00 PM and two (2) staff on 04/03/22 between 10:00 AM to 1:00 PM however, revealed that five (5) of six (6) staff interviewed between 03/26/22 and 04/03/22 believed that there is sufficient staff working at Memory Care unit during this time period. Based on the information gathered during the course of the investigation, the allegations are deemed substantiated at this time.

Citation issued, appeal rights discussed and given. Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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: 10/28/2022
NARRATIVE
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(continued from LIC 9099-C)

Regarding the allegation that due to insufficient staffing residents needs were not met, it was alleged that the memory care unit was understaffed. IB Investigator Spindola’s interview with four (4) staff on 5/27/21, 07/08/21 and 07/14/21 revealed that two (2) out of four (4) staff believed that they were unable to help residents at the memory care unit as they should be due to lack of staff. LPA's interview with four (4) staff on 03/26/22 between 10:00 AM to 2:00 PM and two (2) staff on 04/03/22 between 10:00 AM to 1:00 PM however, revealed that five (5) of six (6) staff interviewed between 03/26/22 and 04/03/22 believed that there is sufficient staff working at Memory Care unit during this time period.

Based on the information gathered during the course of the investigation, the allegation is deemed substantiated at this time.

Citation issued, appeal rights discussed and given.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2022
Section Cited
HSC
1569.312(e)
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Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.

This requirement is not met as evidenced by:
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Executive Director agreed to agreed to submit a Statement of Understanding and step by step plan to avoid similar issues from happening again regarding meeting basic care needs of the residents and will submit to CCL on or before the POC date.
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Based on IB investigator's interview and record review, licensee did not ensure to supervise/monitor the resident to ensure R1's health safety and wellbeing. R1 fell and sustain injuries due to lack of proper supervision/monitoring. This poses an immediate health and safety risk to residents in care.
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Request Denied
Type A
10/31/2022
Section Cited
CCR
87705(c)(4)
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(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.

This requirement is not met as evidenced by:
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Cleared during visit. LPA record review and recent interview with staff revealed that the staff is sufficient at this time.
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Based on IB investigator interview and record review, licensee failed to ensure that there is sufficient staff to care for R1 based on R1's current appraisal. This poses an immediate health and safety risk to the residents in care.
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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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4