336400075-7-2-2021-18-AS-NBRN-C8LPW6-20211109104012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336400075
Report Date: 07/02/2021
Date Signed: 07/02/2021 09:48:37 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2020 and conducted by Evaluator Pauline Beschorner

COMPLAINT CONTROL NUMBER: 18-AS-20200602112630

FACILITY NAME:	ATRIA HACIENDA		FACILITY NUMBER:	336400075
ADMINISTRATOR:	BARTON, ROBERT		FACILITY TYPE:	740
ADDRESS:	44600 MONTEREY AVE		TELEPHONE:	(760) 341-0890
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92260
CAPACITY:	266	CENSUS:	DATE:	07/02/2021
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Victoria Mata		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Due to neglect, resident sustained a fall resulting in a broken arm

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pauline Beschorner conducted this investigation visit to conclude this agency’s investigation into the complaint allegations mentioned above. LPA spoke with Assistant Executive Director Victoria Mata.

During this investigation, interviews were conducted with the Executive Director, staff and independent witnesses. Resident 1’s (R1) Physician Report, Needs and Services Plan and other pertinent documentation was requested and reviewed. LPA was unable to interview R1.

The first allegation alleges due to staff neglect, resident sustained a fall resulting in a broken arm. A review of incident reports submitted to Licensing revealed that R1 was found on floor in R1's apartment next to R1's bed, with a laceration to R1's chin. R1’s responsible party corroborated that R1’s fall on this day, did not result in a broken arm.

CONTINUED ON NEXT PAGE

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline Beschorner	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

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 18-AS-20200602112630

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATRIA HACIENDA	FACILITY NUMBER: 336400075
	VISIT DATE: 07/02/2021

NARRATIVE

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Based on interviews and record review the above allegation is UNFOUNDED, meaning the allegations are false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was reviewed, and appeal rights were provided to Assistant Executive Director Victoria Mata, whose signature on this form confirm receipt of the above-mentioned documents.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline Beschorner	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021

LIC9099 (FAS) - (06/04)

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