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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608685
Report Date: 05/24/2022
Date Signed: 05/24/2022 01:55:17 PM

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
03/09/2020 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20200309111042
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:
05/24/2022
UNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Johnny OrtizTIME COMPLETED:
01:39 PM
ALLEGATION(S):
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Residents door is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit. LPA met with Venca Avivi and discussed the reason for the visit.

---Residents door is in disrepair

It was reported that the resident's door is in disrepair. To investigate this allegation, on 03/11/2022, between 12:30pm - 2:30pm and on 05/02/2022 between 2:15 PM - 3:20 PM, LPA conducted interviews and requested pertinent documents. The interviews revealed that the resident would often aggressively handle the door, motioning the door handle up and down beyond its intended design limitations and it eventually broke. Although documents revealed that a work order was place for repairs on 03/08/2021 at 12:43pm and the door was repaired the following day, the facility failed to completely remove the mechanism from the disrepaired door which resulted in a visitor and resident being locked in the room.
(Cont. on LIC 9099-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: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
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-20200309111042
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: 05/24/2022
NARRATIVE
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Based on interviews, observations and record review, the allegation is SUBSTANTIATED at this time.

No other health and safety hazards were noted during the visit. An exit interview was conducted. A copy of this report, the original LIC 9099-D and Appeal Rights were discussed and provided. The signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20200309111042
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: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee/adminsitrator shall review California Code of Regulations Title 22 section 87303 and submit a written plan to ensure that the facility is in good repair at all times.

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This requirement is met as evidenced by; Based on interviews, record review and observations, the licensee did not comply with the section cited above as the door was left in disrepair while the room was occupied by a resident which poses a potential Health, Safety, or Personal Rights 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: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3