366400985-3-12-2021-18-AS-RLAY-BZCW2B-20210322165400

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366400985
Report Date: 11/18/2020
Date Signed: 03/12/2021 12:49:30 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
06/23/2020 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200623090020

FACILITY NAME:	ATRIA DEL REY		FACILITY NUMBER:	366400985
ADMINISTRATOR:	DEGUZMAN, SAMUEL		FACILITY TYPE:	740
ADDRESS:	8825 BASELINE RD		TELEPHONE:	(909) 989-4346
CITY:	RANCHO CUCAMONGA	STATE: CA	ZIP CODE:	91730
CAPACITY:	145	CENSUS: 85	DATE:	11/18/2020
		UNANNOUNCED	TIME BEGAN:	05:21 PM
MET WITH:	Samuel De Guzman, Executive Director		TIME COMPLETED:	05:26 PM

ALLEGATION(S):

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Facility failed to meet resident's hygiene needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, contacted the facility, via telephone, to deliver the findings of the investigation into the above allegation. The LPA identified herself and discussed the purpose of the call and the elements of the allegation with Executive Director (ED), Samuel De Guzman.

Regarding the allegation, "Facility failed to meet resident's hygiene needs," it was alleged Resident One (R1) was observed covered in their own excrement on June 18, 2020 upon arrival to a local hospital. The allegation was that it was unknown how long R1 had been in this condition. Facility staff interviews revealed R1 was being checked on approximately every two hours by staff the day the incident took place. A Resident Monthly Assignment Report corroborated the interviews; revealing R1 was checked on at 12:00 am and 3:00 am by facility staff the day the incident took place. Staff interviews reported R1 was observed around 5:00 am to be having difficulty controlling their bowel movements and had soiled their clothing and bed sheets. Staff reported they were actively assisting the resident by changing their under garments, clothing and sheets. Interviews and

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

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-20200623090020

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 DEL REY	FACILITY NUMBER: 366400985
	VISIT DATE: 11/18/2020

NARRATIVE

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an Unusual Incident Report revealed emergency medical services were contacted following staff observations of the resident's condition progressing. Interviews with emergency personnel revealed R1 was observed to be covered in their own excrement on June 18, 2020, however, no concerns of neglect were noted. Emergency medical personnel also report to have observed facility staff to have cleaned up the resident prior to transport to the hospital on that same day. Interviews reported no injuries were observed on R1 due to the resident being covered in their own excrement. Therefore, based on timeline obtained during investigation, it appears the resident must have had a subsequent bowel movement during transport. R1 was interviewed, although could not provide a statement on the alleged incident. This allegation is deemed UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted with De Guzman, in which this report was reviewed, and a copy provided via email. Report with facility representative signature was obtained.

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

LIC9099 (FAS) - (06/04)

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