336426083-6-8-2021-18-AS-KCLS-C492QN-20210622173610

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426083
Report Date: 06/08/2021
Date Signed: 06/08/2021 01:57:01 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
09/04/2020 and conducted by Evaluator Deborah Mullen

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200904114245

FACILITY NAME:	ATRIA PARK OF VINTAGE HILLS		FACILITY NUMBER:	336426083
ADMINISTRATOR:	BRYCE MATTHEWS		FACILITY TYPE:	740
ADDRESS:	41780 BUTTERFIELD STAGE RD		TELEPHONE:	(951) 506-5555
CITY:	TEMECULA	STATE: CA	ZIP CODE:	92592
CAPACITY:	143	CENSUS: 77	DATE:	06/08/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Bryce Matthews, Executive Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Due to neglect/lack of supervision resident sustained an injury while in care
Facility did not follow resident’s care plan

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Deborah Mullen conducted an unannounced visit to deliver the findings of the above allegations. LPA met with Bryce Matthews, Executive Director. The investigation included interviews with staff and a review of resident 1’s (R1’s) facility file and medical records. The Department investigated allegations that due to neglect/lack of supervision resident sustained an injury while in care and facility did not follow resident’s care plan.

Allegation #1 - Due to neglect/lack of supervision resident sustained an injury while in care. On 5/26/2020 R1 had an unwitnessed fall in his/her room. The last caregiver to have assisted R1 had left R1’s room “minutes” prior to the fall. When the caregiver left R1 was sitting in the recliner in a reclined position with the footrest up. The caregiver left the room to get R1’s breakfast and before she could come back there was a call over the radio requesting assistance in R1’s room. Based on interviews conducted the allegation could not be corroborated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah Mullen	TELEPHONE: (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)

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Control Number 18-AS-20200904114245

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 – Facility did not follow resident’s care plan. A review of R1’s Functional Needs Assessment indicated resident required “stand-by/remind assistance” because of a low fall risk and that R1 required “limited assistance” of up to 6 times per day for transfer ability. Per interviews with staff, resident was receiving assistance with transferring and standing as indicated in her Functional Needs Assistance.

Based upon the information obtain during the investigation the allegations are unsubstantiated. 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, Administrator.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah Mullen	TELEPHONE: (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)

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