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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000372
Report Date: 09/21/2021
Date Signed: 09/21/2021 02:55:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ATRIA DEL SOLFACILITY NUMBER:
306000372
ADMINISTRATOR:GOODWIN, JEREMIAHFACILITY TYPE:
740
ADDRESS:23792 MARGUERITE PKWYTELEPHONE:
(949) 458-1176
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:120CENSUS: 86DATE:
09/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Irma Arreola and Jeremiah GoodwinTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports submitted to Community Care Licensing. LPA was greeted and granted entry into the facility by Resident Services Director Irma Arreola and Executive Director Jeremiah Goodwin and explained the reason for the visit.

Incident report dated 08/20/2021 indicated facility did not administer Resident 1's (R1) Fentanyl patch as directed. R1 had an order for Fentanyl patch 12mcg, routine every 72 hours, dated 08/18/2021. The medication was not started until family brought it to the facility's attention. Physician as well as hospice notified with no adverse effects noted. Facility received a subsequent order for Fentanyl patch with a start date of 08/20/2021 which was administered. Staff 1 was verbally counseled but did not receive a written warning. S1 has current medication training in the file.

Incident report dated 09/05/2021 indicated Resident 2 was found on the ground in the parking lot outside facility entrance. 911 was called and R2 was transferred to Mission Hospital with bleeding and scrapes to knees. Per physician report dated 03/26/2021, R2 is able to leave the facility unattended and still drives a car.



Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ATRIA DEL SOL
FACILITY NUMBER: 306000372
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2021
Section Cited

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Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
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Based on interview and record review, Licensee failed to ensure care was provided to R1. Fentanyl patch, routine, was prescribed to R1 effective 08/18/2021. S1 did not administer medication until brought to facility's attention on 08/20/21. This poses an immediate health and safety 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021
LIC809 (FAS) - (06/04)
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