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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000752
Report Date: 02/16/2023
Date Signed: 02/16/2023 03:32:10 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/24/2022 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20220524143129
FACILITY NAME:ATRIA GOLDEN CREEKFACILITY NUMBER:
306000752
ADMINISTRATOR:JAMES D. CRADDOCKFACILITY TYPE:
740
ADDRESS:33 CREEK RDTELEPHONE:
(949) 786-5665
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:155CENSUS: 102DATE:
02/16/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Jim Craddock- Executive DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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resident pushing another resident causing an injury due to neglect
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA spoke with Executive Director Jim Craddock and discussed the above allegations.

It was alleged resident pushed another resident causing an injury due to neglect. LPA reviewed pertinent documents such as resident’s physician report, needs and services plan, hospice documentation, and incident reports. The investigation was completed by the Department and revealed the following:

On 4/21/2022 the Department received an Unusual Incident Injury Report (LIC 624) reporting a resident on resident altercation. Per LIC 624 at approximately at 8:00 am Resident 1 (R1) came close to Resident (R2) and reached out to their shoulder. R2 was startled and pushed R1 away. R1 then lost their balance and fell on the floor. R1 was transported to the hospital for further evaluation and R1’s power of attorney (POA) and primary care physician (PCP) were notified.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
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 22-AS-20220524143129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GOLDEN CREEK
FACILITY NUMBER: 306000752
VISIT DATE: 02/16/2023
NARRATIVE
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R1’s Needs and Service plan developed by the facility dated 11/26/2021 stated that R1 requires redirection; However, does not specify if R1 requires a 1:1 caregiver. Based on interviews with staff during the time of the incident caregivers and staff were escorting other residents to breakfast. Staff present during the incident, reported they witnessed R1 walking the hallway and saying something to R2, before R2 then pushed R1. The witness stated they called over a second staff in order to assess R1. They then called over a third staff member in order to help lift R1 up. Staff interviewed reported R1 did not complain of any pain and was placed in a wheelchair.

Based on interviews with 2 out of 4 staff indicate that R1 has been aggressive in the past, but this was monitored and treated with medication and redirection. R1 and R2 were unable to be interviewed as R1 passed away and R2 was not oriented to time and space during the interview. Per interviews with staff R2 was not aggressive and kept to themselves.

Based on the preponderance of the evidence through review of documents and interviews the allegation resident pushing another resident causing an injury due to neglect is UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/24/2022 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20220524143129

FACILITY NAME:ATRIA GOLDEN CREEKFACILITY NUMBER:
306000752
ADMINISTRATOR:JAMES D. CRADDOCKFACILITY TYPE:
740
ADDRESS:33 CREEK RDTELEPHONE:
(949) 786-5665
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:155CENSUS: 102DATE:
02/16/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Jim Craddock- Executive DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not seek timely medical attention for resident who fell
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA spoke with Executive Director Jim Craddock and discussed the above allegations.

It was alleged staff did not seek timely medical attention for resident who fell. LPA reviewed pertinent documents such as resident’s physician report, needs and services plan, hospice documentation, and incident reports.

The Department received an Unusual Incident Injury Report (LIC 624) on 4/21/2022. Per the LIC 624, at approximately at 8:00 am Resident 1 (R1) came close to Resident (R2) and reached out to their shoulder. R2 was startled and pushed R1 away and caused R1 to lose their balance. As a result, R1 fell on the floor. Per LIC 624 the facility stated R1 was transported to the hospital for further evaluation and R1’s Power of Attorney and Primary Care Physician were notified.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20220524143129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GOLDEN CREEK
FACILITY NUMBER: 306000752
VISIT DATE: 02/16/2023
NARRATIVE
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Based on interviews with staff and witness R1’s family called after the incident and was ask if they wanted to take R1 to urgent care. R1’s family came to the facility to pick up R1 and transported them to Hoag Urgent Care at approximately 11:30 AM, resulting in a three and a half hour delay in medical services. R1 was then transferred to the hospital where R1 was diagnosed with a fracture femur. The LIC 624 stated that the resident was transferred to the hospital after 911 was called. Per hospice paperwork, R1 returned back to facility on 04/24/2022 and was placed on continuous care from 04/24/2022 to 05/01/2022 before passing away.

A civil penalty is pending determination, per H&S Code Section 1569.49(e).

Based on the preponderance of evidence through record review and interviews the allegation staff did no seek timely medical attention for resident who fell is SUBSTANTIATED, meaning the complaint allegation as valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8 and civil penalties assessed

An exit interview was conducted and a copy of this report and appeal rights was provided to the Executive Director.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20220524143129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GOLDEN CREEK
FACILITY NUMBER: 306000752
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2023
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…This requirement is not met as evidence by: Licensee failed to seek immediate medical attention following R1’s fall.
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Administrator to provide in service community wide to enforce company policies on seeking timely medical.
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Facility staff instead contacted R1’s responsible party who then sought medical attention. This poses an immediate risk to residents in care. Civil Penalty Assessed in the amount of $500.
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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) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5