197608685-5-14-2023-31-AS-TAGD-CT9UZT-20230629160203

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608685
Report Date: 04/27/2023
Date Signed: 05/14/2023 11:02:13 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
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: 118	DATE:	04/27/2023
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Wendy Rose - Business Office Manager		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff failed to properly report incident to authorized representative

INVESTIGATION FINDINGS:

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This is an amendment of the report issued on 04/27/23 to rectify a typographical error.
Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA met with Business Office manager and informed the purpose of the visit.

LPA conducted physical plant tour at 9:30 AM, requested copy of facility documents relevant to the investigation and reviewed the same from 10:00 AM to 11:30 AM. LPA also conducted interview with staff from 11:30 AM to 12:30 PM. It was alleged that there was no communication from the facility about Resident #1 (R1) to family member (FM) being rushed to emergency surgery for a broken hip on 10/21/19. LPA's record review today between 10:00 AM to 11:30 AM revealed that staff called the family member of R1 and Primary Care Physician (PCP) on the night of the incident on 10/20/19 at around 11:30 PM. LPA's interview with the former Staff #1 (S1) today at 12:10 PM, who attended to R1 on the day of the incident, revealed that S1 was sure that S1 made the call to the family member of R1 after calling 911. Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

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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