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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366400985
Report Date: 04/15/2022
Date Signed: 04/15/2022 01:10:43 PM

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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/08/2022 and conducted by Evaluator Rohit Lama
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220408152008
FACILITY NAME:ATRIA DEL REYFACILITY NUMBER:
366400985
ADMINISTRATOR:DEGUZMAN, SAMUELFACILITY TYPE:
740
ADDRESS:8825 BASELINE RDTELEPHONE:
(909) 989-4346
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:145CENSUS: 86DATE:
04/15/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nicole Stinson, Resident Services DirectorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff gave medication to a resident that was not prescribed for the resident
Staff did not obtain timely medication refill for a resident
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Rohit Lama conducted an unannounced visit to initiate a complaint investigation and deliver the findings for the allegations listed above. LPA met with Nicole Stinson, Resident Services Director.

The first allegation indicates that staff was giving medication that was not prescribed to Resdent #1 (R1). The second allegation states that staff did not obtain a medication refill for R1 in a timely mannar. Interviews with Staff #1 (S1) confirmed that there was a mix-up with the the medication. S1 stated that the medication in question was suppsoed to run out (based on pill count) on 03/26/2022. It is unknown where additional pills of the same medication came from, however, it was noted on 04/07/2022 that the medication had run out. S1 further states that a refill was promptly ordered and the medications arrived in time to give R1's medications as prescribed on 04/08/2022
***** CONTINUED ON LIC 9099-C *****
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit LamaTELEPHONE: 951-217-9826
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
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 4
Control Number 56-AS-20220408152008
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
, CA 92507
FACILITY NAME: ATRIA DEL REY
FACILITY NUMBER: 366400985
VISIT DATE: 04/15/2022
NARRATIVE
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Based on the evidence gathered during investigation, the above allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Section 87464(f)(4) is being cited on the attached LIC 9099-D. Refer to LIC 9099-D dated 04/15/2022 for deficiencies cited. A civil penalty will be assessed for an amount of $100 per day retroactively for the first 15 days if the operator fails to correct the deficiency on the plan of correction (POC) date. Additional fees may be assessed thereafter.

LPA conducted an exit interview where a copy of this report was discussed and provided to the Resident Services Director.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit LamaTELEPHONE: 951-217-9826
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/08/2022 and conducted by Evaluator Rohit Lama
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220408152008

FACILITY NAME:ATRIA DEL REYFACILITY NUMBER:
366400985
ADMINISTRATOR:DEGUZMAN, SAMUELFACILITY TYPE:
740
ADDRESS:8825 BASELINE RDTELEPHONE:
(909) 989-4346
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:145CENSUS: 86DATE:
04/15/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Suby Kumar - Executive DirectorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff do not ensure resident takes medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit on 3/21/23 to deliver an amended complaint finding to the above mentioned allegation. LPA identified herself to executive director (ED) Suby Kumar and resident services director (RSD) Nicole Stinson, who were informed of the reason for today’s visit. The Department conducted the investigation which consisted of inspection of the physical plant, records review, and staff and resident interviews.

The allegation is Staff do not ensure Resident 1 (R1) takes medication. LPA interviewed R1 who stated that staff will give them their medication at the cafeteria or sometimes, when R1 is not in the dining room or their room, staff will leave R1's medication inside their room. R1 stated that they usually take their medication and will inform staff that their medication was taken.

Based on the information obtained the allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with and a copy of this report was provided to administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Leslie MendivelesTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Karen ClemonsTELEPHONE: 951-217-9826
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20220408152008
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
, CA 92507

FACILITY NAME: ATRIA DEL REY
FACILITY NUMBER: 366400985
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited
CCR
87464(f)(4)
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Basic Services: (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications. This
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The Executuive Director has already ensured that appropriate medication has been refilled and an accurate pill count was taken of all medications. Executive Director will provide LPA with proof that an in-service trainning was given to the Med Techs covering the topic of Medication Administration and
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regulation was not met as evidenced by: Staff #1 (S1)'s admission that medication was not administrered as prescribed and was not refilled in a timely mannar. This poses a potential heatlh and safety risk for residents in care.
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Management by Plan of Correction (POC) due date of 04/29/22.The proof will be in the form of a document stating what topic was discussed along with printed names and signatures of all staff that attended the training.
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit LamaTELEPHONE: 951-217-9826
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4