197608685-1-29-2022-31-AS-NMAN-CD6V9P-20220404161438

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608685
Report Date: 01/29/2022
Date Signed: 01/29/2022 01:41:49 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
03/18/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210318171317

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: 94	DATE:	01/29/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	John Spohn - Staff		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff hit resident

INVESTIGATION FINDINGS:

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This is an amendment of the report generated on 08/19/21 to change the findings.

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA met with Executive Director Johnny Ortiz and explained the reason for the visit.

LPA conducted physical plant tour at 10:11 AM. LPA requested facility documents relevant to the investigation at 10:30 AM and interviewed the Executive Director between 11:00 AM to 11:30 AM. LPA's interview with Staff #1 (S1) on 03/26/21 at 3:44 PM, revealed that on 03/10/21 at around 4:30 PM, S1 witnessed Staff #2 (S2) heavily slapping Resident #1 (R1) at the back to stop R1 because R1 was throwing a fit and throwing food while eating at the dining area of the memory care unit. LPA's interview with the Executive Director on 03/26/21 at 3:00 PM revealed that S2 was immediately suspended on the same day of the incident, eventually terminated on 03/16/2021 and did not work again at the facility to date.(continued on LIC 9099-C)

Substantiated

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: 01/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2022

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 3

Control Number 31-AS-20210318171317

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: 01/29/2022

NARRATIVE

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(continued from LIC 9099)

LPA record review today at 12:00 PM, revealed that S2 was trained by the facility to handle Dementia residents including but not limited to Managing Challenging Behaviors on 10/07/2019 and 10/11/2019, certified to have read and understood the Employee Handbook on 09/26/19, which includes the section Terminable Misconduct, that states: "Any acts of abuse, neglect and/or mistreatment toward Atria residents, your supervisor, fellow employees, visitors or volunteers", which was the reason for S2's termination on record.

Based on the information gathered during this and prior visit, while the facility provided training to S2 to avoid any misconduct and immediately relieved S2 of duties to avoid recurrence of S2's misconduct, the fact remained that S2 hit R1 heavily on the back on 03/10/21 as witnessed by S1. The allegation is therefore deemed substantiated at this time.

Citation issued. Appeal rights discussed and given. 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: 01/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20210318171317

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: 01/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/31/2022 Section Cited HSC 1569.269(a)(10)	1 2 3 4 5 6 7	Enumerated rights; severability - (10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility staff agreed to inform the Executive director to train all staff regarding residents' personal rights and submit a copy of proof of training including but not limited staff attendace to CCL on or before the POC date.
	8 9 10 11 12 13 14	Based on LPA interview, the licensee failed to ensure that R1's personal rights was observed and respected by the staff. This poses an immediate safety and personal righs risk to the resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2022

LIC9099 (FAS) - (06/04)

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