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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426083
Report Date: 06/08/2021
Date Signed: 06/08/2021 01:56:17 PM



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
09/01/2020 and conducted by Evaluator Deborah Mullen
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200901084209
FACILITY NAME:ATRIA PARK OF VINTAGE HILLSFACILITY NUMBER:
336426083
ADMINISTRATOR:BRYCE MATTHEWSFACILITY TYPE:
740
ADDRESS:41780 BUTTERFIELD STAGE RDTELEPHONE:
(951) 506-5555
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:143CENSUS: 77DATE:
06/08/2021
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Bryce Matthews, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Grab bars are not installed in residents bathrooms
Staff failed to distribute medication to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Deborah Mullen conducted an unannounced visit to complete the investigation of the above allegation. LPA met with Bryce Matthews. The investigation involved staff and witness interviews and LPA observations of the facility.

Allegation #1 states grab bars are not installed in residents (R1's) bathroom. LPA observed R1's bathroom and observed it to be void of grab bars next to the toilet. Mr. Matthews had a pull down grab bar installed for the toilet once it was brought to his attention.

Allegation #2 states staff failed to distribute medication to resident. LPA interview with staff 1 (S1) revealed that R1 did not receive her 4am medication on August 25, 2020. S1 stated the staff had returned from vacation and was not aware of the 4am medication distribution. LPA obtained and reviewed R1's medication distribution logs which documented that on August 25, 2020 R1 did not receive the 4am medication.

Based upon interviews and LPA observations the allegations are substantiated and in accordance with Title 22 Regulations, Section 87303 and 87465 citations are being. An exit interview was conducted and this report was reviewed with and provided to Mr. Matthews.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
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 4
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
09/01/2020 and conducted by Evaluator Deborah Mullen
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200901084209

FACILITY NAME:ATRIA PARK OF VINTAGE HILLSFACILITY NUMBER:
336426083
ADMINISTRATOR:BRYCE MATTHEWSFACILITY TYPE:
740
ADDRESS:41780 BUTTERFIELD STAGE RDTELEPHONE:
(951) 506-5555
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:143CENSUS: 77DATE:
06/08/2021
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Bryce Matthews, Executive DirectorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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2
3
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5
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9
Staff is not providing incontinence care to resident
Licensee failed to abide by admission agreement
INVESTIGATION FINDINGS:
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5
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13
Licensing Program Analyst (LPA) Deborah Mullen conducted an unannounced visit to complete the investigation of the above allegations. LPA met with Bryce Matthews, Executive Director. The investigation involved interviews with staff and additional witnesses and a review of resident's (R1's) facility file.

Allegation # 1 states staff is not providing incontinence care to resident. Staff interviewed denied the allegation that R1 was not being provided incontinence care. LPA also reviewed facility log sheets which showed the resident was receiving care services by the caregivers every two hours. Additional witness interviews providing conflicting information that R1 was not receiving the assistance needed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
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 4
Control Number 18-AS-20200901084209
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 PARK OF VINTAGE HILLS
FACILITY NUMBER: 336426083
VISIT DATE: 06/08/2021
NARRATIVE
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Allegation # 2 stated licensee failed to abide by admissions agreement. Staff interviewed denied the allegation that the admissions agreement was not being abided by. Interviews provided information that R1 was receiving the care as identified in R1's needs assessment. LPA reviewed logs of care services provided to R1 which documented R1 was being checked on every 2 hours.

Based upon the information obtained through staff and witness interviews and a review of facility documentation there is not enough evidence to corroborate the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed with and provided to Bryce Matthews, Executive Director.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 18-AS-20200901084209
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 PARK OF VINTAGE HILLS
FACILITY NUMBER: 336426083
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2021
Section Cited
CCR
87303(e)(4)
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Maintenance and Operation:
(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet; bathtub and shower used by residents.
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The facility will ensure grab bars are installed in each resident's bathroom in accordance with regulations. Proof of correction will be submitted to the Department by 7/8/21.
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This requirement was not being met as evidenced by: LPA observed R1's bathroom to be void of a grab bar for use next to the toilet. This poses a potential health and safety risk to residents in care.
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Type B
06/18/2021
Section Cited
CCR
87465(a)(5)
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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed.
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The Licensee will provide in-service training to staff regarding incidental medical and dental care as described in 87465. Licensee will submit proof of correction to the Department by 6/18/21.
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This requirement was not being met as evidenced by: Based on staff interviews and a review of R1's medication distribution log, R1 did not receive medication as prescribed on 8/25/21. This posed a potential health and safety risk to resident 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: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4