197801052-9-2-2021-28-AS-WSHO-C6UKKT-20210914075852

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197801052
Report Date: 09/02/2021
Date Signed: 09/02/2021 03:27:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/16/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210816152606

FACILITY NAME:	ATRIA RANCHO PARK		FACILITY NUMBER:	197801052
ADMINISTRATOR:	STEVEN SCIURBA		FACILITY TYPE:	740
ADDRESS:	801 CYPRESS WAY		TELEPHONE:	(626) 339-5426
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	200	CENSUS: 118	DATE:	09/02/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Yvonn Fuentes, Resident Services Supervisor		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Resident hit by staff resulting in injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegation listed above. LPA met with Resident Services Supervisor, Yvonn Fuentes and explained the reason for the visit. The initial complaint visit was conducted on 8/18/21.

The investigation consisted of the following: LPA obtained a staff schedule and staff contact information. Interviews were conducted with 10 residents and 8 staff. A nurse aid from Bright Haven Hospice was also interviewed. Facility was toured including first floor, second floor, fifth floor and seventh floor.

The investigation revealed the following: It's alleged Resident #1 (R1) was struck by a facility staff member. Staff interviewed indicated they have not witnessed anyone abuse R1. Staff reported seeing a bruise near R1's left eye, but it is unknown what caused the bruise. Facility completed an incident report dated 8/16/21. The report indicates that R1's hospice aid notified facility staff that R1 had a bruise near the left eye. Facility staff had R1 transferred to the hospital and R1 returned from the hospital the same day. Continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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 28-AS-20210816152606

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ATRIA RANCHO PARK	FACILITY NUMBER: 197801052
	VISIT DATE: 09/02/2021

NARRATIVE

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R1 was interviewed and indicated he/she was struck by a female staff member of the facility. R1 did not know the name of the staff member and could not give a detailed description of the staff. R1 indicated no one else witnessed the incident. Allegedly the incident occurred on 8/14/21. Other residents interviewed indicated they had no knowledge of the incident. Residents describe the staff as "nice" and all reported feeling safe in the facility. The physical plant was toured and there were no cameras observed in the hallways or any where near R1's room. R1's hospice aid was interviewed and confirmed she notified facility staff of the bruise, but did not know the source of the bruise. The hospice aid indicated she has never seen any suspicious bruises on R1 before.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview held. A copy of the report was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC9099 (FAS) - (06/04)

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