197801052-9-2-2021-28-AS-WSHO-C873VH-20211026183509

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197801052
Report Date: 09/02/2021
Date Signed: 09/02/2021 03:25:30 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
08/26/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210826113219

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:	10:59 AM
MET WITH:	Yvonn Fuentes, Resident Services Supervisor		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Facility is unable to provide alternative power supply during outages.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegation listed above. LPA met with Resident Services Supervisor, Yvonn Fuentes and explained the reason for the visit.

The investigation consisted of the following: LPA obtained a resident roster. Interviews were conducted with 9 residents and 4 staff. Facility was toured including all 7 floors and generator area.

The investigation revealed the following: Facility staff confirmed the generator has not been working for a couple of months. Staff reported that Edison has been working on nearby projects and has been cutting the power to the facility. Staff report there has been at least 10 power outages within a 3 month period. Staff report the outages have lasted up to an hour. Staff report that corporate has been inquiring about replacing the generator. Staff said they have provided all residents with flashlights and staff walk around with additional lights when the power goes out. There are some residents that use oxygen machines that need power to function. Staff report that they check on those residents first and change to oxygen tanks that don't require power.
Continued on 9099C.

Substantiated

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)

Page: 1 of 5

Control Number 28-AS-20210826113219

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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Residents interviewed confirmed the power outages. Residents confirmed they have multiple flashlights in their rooms. LPA also observed flashlights in residents' rooms during interviews. LPA observed the generator located in the rear of the building. Maintenance indicated the generator needs to be fixed or replaced. Cracks were found in the generator when facility attempted to repair it.

Based on interviews conducted and observations, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview held. A copy of the report and appeal rights were 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)

Page: 2 of 5

Control Number 28-AS-20210826113219

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/16/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation 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.	1 2 3 4 5 6 7	Facility will submit invoices for any repairs or replacement of generator. Facility will also submit a plan describing how facility will keep residents safe during power outages. Facility will also reach out to Edison to ask if they can notify the facility when the power will be turned off in the area.
	8 9 10 11 12 13 14	Deficiency was evidenced by the following: Staff confirmed the power outages and confirmed the generator is not operating. Residents also confirmed the issue.	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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
08/26/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210826113219

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:	10:59 AM
MET WITH:	Yvonn Fuentes, Resident Services Supervisor		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Facility does not have sufficient emergency lighting.

INVESTIGATION FINDINGS:

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13

Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegation listed above. LPA met with Resident Services Supervisor, Yvonn Fuentes and explained the reason for the visit.

The investigation consisted of the following: LPA obtained a resident roster. Interviews were conducted with 9 residents and 4 staff. Facility was toured including all 7 floors and generator area.

The investigation revealed the following: The facility was toured and flashlights were observed in residents' rooms and some had multiple flashlights. Staff also have additional lights that they place in the hallway during a power outage. Staff report they check on all the residents during a power outage and 1 staff will stay in the hallways of each floor in case a resident needs assistance. Residents interviewed confirmed that staff check on them during the outages.

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)

Page: 4 of 5

Control Number 28-AS-20210826113219

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
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	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)

Page: 5 of 5