197801052-5-25-2023-28-AS-TVAO-CS6S6P-20230525133613

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197801052
Report Date: 05/23/2023
Date Signed: 05/25/2023 08:48:40 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
07/21/2021 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210721085127

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:	0	CENSUS: 0	DATE:	05/23/2023
		UNANNOUNCED	TIME BEGAN:	11:29 AM
MET WITH:	Alondra Fuentes		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident passed away from malnutrition while in care.
Resident passed away from dehydration while in care.
Resident sustained a fall while in care resulting in a fracture.
Staff did not ensure that resident was adequately fed and hydrated while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez delivered findings on 05/18/23. Due to Atria Rancho Park no longer being in operation, LPA met with the Administrator Alondra Fuentes of Atria Covina via telephone to deliver findings. LPA explained the purpose of the call.

The investigation consisted of the following: On 7/22/2021 LPA Wesley conducted 24-hour health and safety inspection. LPA Wesley requested copy of the staff roster, resident roster, food menu, resident #1’s (R1): Admission Agreement, Physician's Report, Needs and Services Plan, and Unusual Incident Reports. Investigation Bureau (IB) of the Department conducted the investigation, interviews and requested additional documents. On 7/29/2021, IB Investigator Douglas Real contacted staff #1(S1) telephonically. On 10/25/2021, IB Investigator Real completed his investigation. R1 passed away and was unable to be interviewed. Subsequent visit dated 03/27/23 was recorded as a Case Management visit under West Park Senior Living 198603550 due to LPA requiring more information on the closure of Atria Rancho Park and West Park Senior Living not being affiliated with Atria Rancho Park. On 5/18/23, LPA Ramirez delivered findings via telephone to Administrator Fuentes.

SEE 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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-20210721085127

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ATRIA RANCHO PARK	FACILITY NUMBER: 197801052
	VISIT DATE: 05/23/2023

NARRATIVE

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Allegations:

Resident passed away from malnutrition while in care. It is alleged R1 died from malnutrition while in care. Based on record review of R1’s Death Certificate and medical records, R1’s cause of death was not related to malnutrition. Physician notes dated 06/25/2021 did not note any concerns of abuse or neglect. Staff #1(S1) denied this allegation.

Resident passed away from dehydration while in care. It is alleged R1 died from dehydration while in care. Based on record review of R1’s Death Certificate and medical records, R1’s cause of death was not related to dehydration. Physician notes dated 06/25/2021 did not note any concerns of abuse or neglect. Staff #1(S1) denied this allegation.

Resident sustained a fall while in care resulting in a fracture. It is alleged R1 suffered a fall while in care which resulted in a fracture. Based on staff progress notes for R1, on 6/16/21 R1 had a witnessed fall. R1 was observed on 6/16/21 to have turned and gone down to the floor. R1 was observed getting up off floor unassisted by staff. Staff reminded R1 to make slower turns to minimize falls. LPA Ramirez discovered on 6/17/21, R1 did not report any complaints to staff regarding fall on 6/16/21. Per staff notes, on 6/18/21, R1 reported to staff of pain to left side. Family was made aware according to staff notes. On 6/19/21, R1 reported to staff there was pain when R1 walked and wished to go to the VA hospital after 6/22/21. According to this entry, R1 made his/her family aware he/she would go to the VA hospital after R1 celebrated a special occasion that was approaching. Staff reported not seeing any visible signs of pain or discomfort on 6/19/21. Later in the day of 06/19/21, R1 pushed emergency pendant and was discovered on the bathroom floor by staff. R1 denied any pain and family notified of fall. On 6/20/21, R1 did not report any complaints due to fall. Staff noted a small skin tear to R1’s back and administered first aid. On 6/25/21 during bed checks, staff found R1 on the floor next to their bed. R1 did not complain of pain but staff noted to seeing small skin tear on R1’s left elbow and administered first aid. R1 was taken to the doctor by family on 6/25/21. On 06/27/21, staff noted R1 would be receiving 2-hour status checks based on previous falls. LPA was able to review R1’s X-ray result dated 6/25/21 and it does confirm R1 did have a fracture. Although, R1 did have falls between 6/16/21 through 6/25/21, and did sustain a fracture because of fall(s), LPA could not determine that the facility or its staff were negligent or did not provide adequate care for injury. Staff interviewed denied this allegation.

SEE 9099-C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210721085127

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ATRIA RANCHO PARK	FACILITY NUMBER: 197801052
	VISIT DATE: 05/23/2023

NARRATIVE

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Staff did not ensure that resident was adequately fed and hydrated while in care. It is alleged staff did not adequately feed and hydrate R1 while in care. Based on physician progress notes, LPA was able to confirm that R1 was dehydrated on or around 6/25/21. Facility staff was notified by the doctor and agreed to care of plan for R1. Records review of R1’s Physician Report dated 2/19/21, confirms R1 did not require assistance with meals. LPA Ramirez discovered Resident Functional Needs Service plan dated 6/30/21, and it states R1 will require assistance to attend meals and activities. LPA could not find any pertinent documents that suggest staff failed to feed and hydrate R1. LPA could not confirm staff did not assist R1 to attend meals. Staff interviewed denied this allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was held telephonically and a copy of this report was emailed for signature.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

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