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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426083
Report Date: 04/20/2022
Date Signed: 04/21/2022 10:57:29 AM

Substantiated


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
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: 112DATE:
04/20/2022
UNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Quinn HernandezTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility is restricting (private) visitations.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived at the facility to deliver findings for the mentioned allegation. LPA Prieto met with Director Quinn Hernandez. During LPA visit, on 10/22/2019, resident #1 (R1) was interviewed in her private apartment. Facility Director and R1's private nurse were in the apartment during the interview, thus restricting R1's privacy to confidential visit.

Based on LPA observations and interviews which were conducted. Preponderance of evidence standard has been met. Therefore, the above allegation(s) is Substantiated. California Code of Regulations (Title 22, Division & Chapter number) are being cited on the attached LIC 9099D).
Substantiated
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: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
04/27/2022
Section Cited
CCR
87468.1(a)(1)
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87468.1 (a)(1) PERSONAL RIGHTS OF RESIDENT IN ALL FACILITIES. Residents in all residential care facilities for the elderly shall have the following personal rights.
To be accorded dignity in their personal relationship with staff, residents and other persons. This was not met, as evidenced by:
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Facility administrator to submit declaration the resident interviews and visit will be private.

Declaration to be submitted in writing to LPA by Plan of Correction (POC) date.
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During time of resident interview, facility staff the resident nurse were present thus not allowing for resident private interview.
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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: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2