306000752-5-7-2024-22-AS-AJLO-D5PTDL-20240528143831

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000752
Report Date: 04/26/2024
Date Signed: 05/07/2024 02:47:42 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
12/15/2020 and conducted by Evaluator Dwayne L Mason

COMPLAINT CONTROL NUMBER: 22-AS-20201215112452

FACILITY NAME:	ATRIA GOLDEN CREEK		FACILITY NUMBER:	306000752
ADMINISTRATOR:	WENTWORTH, NICOLE		FACILITY TYPE:	740
ADDRESS:	33 CREEK RD		TELEPHONE:	(949) 786-5665
CITY:	IRVINE	STATE: CA	ZIP CODE:	92604
CAPACITY:	155	CENSUS: 100	DATE:	04/26/2024
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Dorice Redman - Executive Director		TIME COMPLETED:	09:35 AM

ALLEGATION(S):

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Resident sustained an injury from a fall while in care

INVESTIGATION FINDINGS:

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This is an amended report.

This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by Receptionist Maria McKennett.

LPA met with Executive Director, Dorice Redman (ED) and explained the nature of the inspection. The department received a complaint on 12/15/2020 alleging a resident sustained an injury from a fall while in care. The Reporting Party (RP) disclosed that a resident was hospitalized for major blunt trauma due to an unwitnessed fall. During the investigation, the department interviewed Executive Director, staff and residents.

(continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

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 22-AS-20201215112452

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ATRIA GOLDEN CREEK	FACILITY NUMBER: 306000752
	VISIT DATE: 04/26/2024

NARRATIVE

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This is an amended report

(continued from LIC9099)

On 4/3/2024 LPA conducted interview with Executive Director (ED) Dorice Redman. ED stated that she started working at the facility in March of 2024. ED made no disclosures regarding allegation.

LPA attempted to interview the Reporting Party (RP) twice by calling the phone number provided on 4/2/2024 at 1:31 pm and again on 4/3/2024 at 10:13am. LPA was told to expect a call back by the end of the day on 4/3/2024. LPA did not receive a call back.

On 4/3/2024 LPA conducted interviews with Executive Director (ED) and facility staff. No disclosures were made regarding the allegation. LPA interviewed Resident 1 and Resident 2 who resided at the facility during the time of the allegation. No disclosures were made regarding the allegation. LPA could not interview the Alleged Victim (AV) because they passed away in December 2020.

LPA obtained copies of the following files: resident roster, staff roster, staff schedule, incident reports, pre-placement appraisal, needs assessment, needs profile and physician's report.

Based on record review, LPA determined R1 was diagnosed with dementia and required checks at approximately 12am, 2am, 4am and 6am. Based on interview with Staff 1, it was stated that R1 was checked on at approximately 4:30am on 12/12/2020 and that is when the resident was found on the floor.

Based on interviews conducted and records reviewed LPA determined that the facility conducted their nightly checks and Staff 1 discovered Resident 1 on the floor. Therefore, there is insufficient evidence to indicate that this occurred as a result facility negligence. Although the allegation(s) may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and this report was reviewed with Executive Director. A copy of this LIC-9099 was provided to the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

LIC9099 (FAS) - (06/04)

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