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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426083
Report Date: 11/09/2021
Date Signed: 11/09/2021 12:12:22 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
02/14/2020 and conducted by Evaluator Javier Prieto
COMPLAINT CONTROL NUMBER: 18-AS-20200214084753
FACILITY NAME:ATRIA PARK OF VINTAGE HILLSFACILITY NUMBER:
336426083
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:41780 BUTTERFIELD STAGE RDTELEPHONE:
(951) 506-5555
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:143CENSUS: DATE:
11/09/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Bryce MatthewsTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident sustained a fracture due to staff neglect
Staff did not report fall to responsible party
Insufficient staffing to meet resident's needs
Staff did not safeguard resident's medical information
Staff did not ensure provision of medical care to meet resident needs.
Facility is not administering medications as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto and LPA Lama conducted an unannounced visit to the facility to deliver the finding of the above allegation. LPA met with Director Bryce Matthews.

The investigation was conducted by the Department. The investigation consisted of file review and interviews with relevant parties. Based upon investigation, there is insufficient evidence to substantiate the allegation of Neglect/Lack of Care, resulting in resident 1, (R1) fracture. The investigation revealed that R1 was assessed as a fall risk and monitored by facility staff and hospice staff. The staff addressed R1’s issues related to pain on 1/23/21, and staff ordered x rays. The results came back fracture. Interviews and documentation obtained revealed the facility staff communicated with R1’s responsible party as well as all parties involved to ensure care needs were met. LPA reviewed R1’s facility file and observed the documents safeguarded and properly stored. There is no evidence to corroborate that staff did not safeguard resident's medical information. Documentation obtained shows medications were given as prescribed. R1 was on fall plan and the plan was updated as needed. Based on interviews conducted and documents review the mentioned allegations are unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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 2
Control Number 18-AS-20200214084753
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: 11/09/2021
NARRATIVE
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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.
No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the caregiver.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2