306005290-11-4-2020-22-AS-SSAS-BVF925-20201116215835

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005290
Report Date: 11/04/2020
Date Signed: 11/04/2020 09:19:35 AM

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
05/15/2020 and conducted by Evaluator Albert Marin

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200515111128

FACILITY NAME:	ATRIA PARK OF WOODBRIDGE		FACILITY NUMBER:	306005290
ADMINISTRATOR:	TAMMIE SAMPEDRO		FACILITY TYPE:	740
ADDRESS:	1 WITHERSPOON		TELEPHONE:	(949) 654-8500
CITY:	IRVINE	STATE: CA	ZIP CODE:	92604
CAPACITY:	180	CENSUS: 75	DATE:	11/04/2020
		UNANNOUNCED	TIME BEGAN:	08:42 AM
MET WITH:	Executive Director Tammie Sampedro		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff handled resident in rough manner.
Staff yelled at resident.

INVESTIGATION FINDINGS:

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As precautionary measure during the Coronavirus 2019 pandemic, Licensing Program Analyst (LPA) Albert Marin made an unannounced video teleconference to this facility. LPA spoke with Executive Director (ED) Tammie Sampedro; and stated the purpose of this teleconference, which was to deliver the findings for the investigation conducted for the complaint filed against this facility last May 15, 2020.

On the allegation the staff handled the resident in rough manner, the following are the findings. It was reported that on May 7, 2020 Two staff members went inside the resident’s room to assist the resident for personal care. Resident was agitated; and Staff 1 reacted by pushing and roughly assisting the resident with personal care. Per interviews, two witnesses observed the incident between Resident 1 and Staff 1. On May 13, 2020 report was completed and provided to Community Care Licensing Division (CCLD) Orange Office.

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020

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-20200515111128

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 PARK OF WOODBRIDGE	FACILITY NUMBER: 306005290
	VISIT DATE: 11/04/2020

NARRATIVE

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On the allegation the staff yelled at the resident, the following are the findings. It was reported that on May 7, 2020 two staff members went inside the resident’s room to assist the resident for personal care. Resident was agitated and was yelling. Staff 1 reacted by yelling back to the resident, throwing a towel on the resident's face and went to finish assisting resident with personal care. Per interviews, two witnesses observed the incident between Resident 1 and Staff 1. On May 13, 2020 report was completed and provided to Community Care Licensing Division (CCLD) Orange Office.

The preponderance of the evidences for the allegations that the staff handled the resident in a rough manner; and staff yelled at the resident had been met. Therefore, the above allegations are found SUBSTANTIATED.

Based on the above findings, deficiencies were observed. Citations were issued per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview and read the report with ED Sampedro. LPA discussed the deficiencies and citations; and reviewed the appeal rights to ED. LPA will provide copy of this report, deficiency page, copies of the cited regulations, and appeal rights via email. As agreed, ED will acknowledge their receipt.

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SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20200515111128

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 PARK OF WOODBRIDGE	FACILITY NUMBER: 306005290
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/04/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/04/2020 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	As plan of correction, Facility conducted an investigation on the incident; and issued corrective actions on employees involved. Threat was reduced. Facility will continue to give regular training to staff members on resident's personal rights. - Deficiency cleared during the course of the investigation.
	8 9 10 11 12 13 14	Based on the investigation conducted, the facility missed to accord residents with dignity in their personal relationships with staff. Staff 1 assisted residents in rough manner, yelling at resident and without consideration to the capacity of the resident to follow instructions and prompts. This posed direct threat to the personal rights of the residents in care.	8 9 10 11 12 13 14	LPA provided copy of the cited regulation for full reference.
Type B 11/18/2020 Section Cited CCR 87211(c)	1 2 3 4 5 6 7	Reporting Requirements. Any suspected physical abuse that does not result in serious bodily injury ...shall be reported to ...the corresponding licensing agency ...within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	As plan of correction, facility will prioritize the reporting of all forms of abuse within the required period for reporting. Facility will conduct regular review of the reporting protocol of the facility with staff members. Deficiency cleared during the course of the investigation.
	8 9 10 11 12 13 14	Based on the investigation conducted, the facility missed to report the suspected physical abuse with no serious bodily injury to the licensing agency within 24 hours. Incident occurred on 5/7/2020. Facility called filed the report on May 13, 2020. This poses potential threat on the health and safety of residents in care.	8 9 10 11 12 13 14	LPA provided copy of the cited regulation for full reference.

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: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020

LIC9099 (FAS) - (06/04)

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