197608685-11-9-2022-31-AS-TAGD-CT9UZU-20230629160205

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608685
Report Date: 11/09/2022
Date Signed: 11/09/2022 02:57:36 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
02/25/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20200225154209

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: 113	DATE:	11/09/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Venca Avivi - Resident Services Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff diagnosed resident without proper consent

Resident sustained an injury from a fall while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with Resident Services Director Venca Avivi and explained the reason for the visit.

LPA conducted physical plant tour at 9:40 AM, requested copy of facility documents relevant to the investigation and reviewed the same from 10:00 AM to 1:00 PM. LPA also conducted interview with staff from 1:00 PM to 2:30 PM.

Regarding the allegation that staff diagnosed resident without proper consent, it was alleged that the facility did not inform Resident #1 (R1)'s family member regarding a doctor's visit to evaluate R1 which resulted to a new diagnosis. LPA's record review today between 10:00 AM to 1:00 PM revealed that R1 was already diagnosed with Dementia prior to moving in at the facility. Further review also revealed that it was R1's PCP who ordered the evaluation and not the facility staff. (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: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

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-20200225154209

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: 11/09/2022

NARRATIVE

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(continued from LIC 9099)

LPA's interview with the Resident Service Director today at around 1:00 PM, also revealed that they were not aware of the PCP's ordered evaluation until the evaluating doctor arrived at the facility.

Regarding the allegation that resident sustained an injury from a fall while in care, it was alleged that R1 fell on the night of 10/20/19 and was rushed to the hospital for an emergency surgery for a broken hip. LPA's record review today between 10:00 AM to 1:00 PM revealed that R1 was assessed by a third party out of state nurse prior to move in on 07/19/19 and was assessed to be a minimal fall risk and was assessed by an out of state physician on 07/10/19 to be ambulatory but requires walker. Pre move in appraisal of the facility dated 07/30/19 also revealed that R1 requires only minimal fall assistance but was placed on status check every two (2) hours. This is consistent with Move in Assessment dated 08/21/19 and Thirty (30) day Assessment of R1 dated 09/19/19. LPA's interview with three (3) care staff who attended to R1 during R1 stay at the facility on 11/05/22 between 11:30 AM to 1:45 PM and two (2) care staff today between 1:00 PM to 2:30 PM revealed all five (5) of them do check R1 every two (2) hours as scheduled on their daily assignment to ensure that R1 was doing well.

Based on the information gathered during this and prior visits, the allegations are 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: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

LIC9099 (FAS) - (06/04)

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