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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426083
Report Date: 11/02/2021
Date Signed: 04/21/2022 10:55:30 AM

Unsubstantiated


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
10/15/2019 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191015164109
FACILITY NAME:ATRIA PARK OF VINTAGE HILLSFACILITY NUMBER:
336426083
ADMINISTRATOR:RUSSELL, SAMMYFACILITY TYPE:
740
ADDRESS:41780 BUTTERFIELD STAGE RDTELEPHONE:
(951) 506-5555
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:143CENSUS: 93DATE:
11/02/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Bryce MatthewsTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility failed to give resident's responsible party written notice of change in care.

Facility failed to promptly answer communications from resident's responsible party.

Facility failed to allow resident's responsible party prompt access to resident's records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived at the facility to deliver findings on the mentioned allegations. LPA Prieto met with Director Quinn Hernandez. Interview resident #1's responsible party concluded that they were notified of R1s change in care. Documentation, dated 10/01/2019, documents the responsible party asking for additional services and a response from the facility Director that services would be provided a discussion of level of care will be needed in the future.

Facility documentation obtained reveal communication, with responsible party, were held related to care of R1 and obtaining updated doctor's orders. Email documentation was obtained showing time and dates of communication with the responsible party related to a change condition and care from the facility Director to the responsible party.
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: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
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-20191015164109
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: 11/02/2021
NARRATIVE
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Based on interviews conducted and information obtained there is not enough evidence to corroborate the mentioned allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2