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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608685
Report Date: 01/03/2022
Date Signed: 02/22/2022 08:51:44 PM



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
10/20/2021 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20211020154028
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: 103DATE:
01/03/2022
UNANNOUNCEDTIME BEGAN:
02:51 PM
MET WITH:Johnny OrtizTIME COMPLETED:
04:52 PM
ALLEGATION(S):
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Staff did not report incident to resident's responsible party.
Resident suffered from significant weight loss.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA was screened for COVID 19 and met with Executive Director (ED) Johnny Ortiz.

----- Staff did not report incident to resident's responsible party.
It was alleged that staff did not report incident to resident's responsible party. To investigate these allegations, on 10/26/2021 at 3:30pm, LPA spoke with staff and other parties. In addition, on 10/26/2021 at 4:10pm, LPA observed resident #1 (R1), requested R1’s facility files and researched prior incident reports. After careful review, it was determined that R1 did sustain a small injury, there were hazardous materials found in R1’s room, it was reported to staff, but an incident report was not filed, and the responsible party was not notified timely.
Based on the information from interviews and records review, the allegation is SUBSTANTIATED at this time.
Deficiencies cited on LIC 9099-D.
(CONT. LIC9099-C)

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
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-20211020154028
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: 01/03/2022
NARRATIVE
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----- Resident suffered from significant weight loss.

It was alleged that resident has significant weight loss since she moved in. To investigate these allegations, on 10/26/2021 at 3:30pm, LPA spoke with staff and other parties. In addition, on 11/17/2021 at 12:30pm, LPA requested documents from R1’s most recent doctor’s visit. Record review revealed that R1 has a diagnosis of dementia with behavioral disturbances, lost significant weight, that the facility reported a change of condition (decreased appetite, won’t sit during meals) to the doctor and doctor responded, “At this time there is no new order.” On 11/17/2021 at 11:30am, LPA observed R1 in the dining room during an unannounced visit and R1 was eating independently with other residents.

Based on the observations, information from interviews and records review, the allegation is SUBSTANTIATED at this time, however, NO CITATION was issued as the weight loss was not caused by neglect of the facility, but rather R1’s medical condition.

No health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20211020154028
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: 01/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2022
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements (a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D).. Any incident which threatens the welfare, safety or health
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Executive Director will provide training to staff for reporting requirements. Proof of completion of trainings will be submitted by e-mail by the plan of correction due date.
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of any resident....This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not file an incident report and did not notify the resident’s responsible party. This poses a potential health safety risk to 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: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
10/20/2021 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20211020154028

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: DATE:
01/03/2022
UNANNOUNCEDTIME BEGAN:
02:51 PM
MET WITH:Johnny OrtizTIME COMPLETED:
04:52 PM
ALLEGATION(S):
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Facility has insufficient staffing.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA was screened for COVID 19 and met with Executive Director (ED) Johnny Ortiz.
It was alleged that there is only one staff on the floor and sometimes there is no caregiver. To investigate these allegations, on 10/26/2021 at 3:30pm, LPA interviewed staff and other parties. In addition, on 10/26/2021 at 3:00pm, LPA observed the facility and requested the staff schedule and resident list. Interviews and record reviews revealed that there is one care staff member per floor with one additional staff member designated as a “floater” and a Med Tech for ten (10) residents per floor per shift in the memory care unit. On 10/26/2021 at 4:10pm, LPA interviewed residents and it was determined that all care needs were being met, all rooms were clean, well furnished and all residents were well groomed.
Based on the information from interviews and records review, the allegation is UNSUBSTANTIATED at this time.
No health and safety hazards were noted during the visit.
Exit interview was conducted and a copy of the report was issued.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4