366400985-9-14-2022-56-AS-KCLS-CW3M8K-20230927092313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366400985
Report Date: 09/14/2022
Date Signed: 09/14/2022 01:15:49 PM

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/12/2022 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220912103105

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: 88	DATE:	09/14/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Executive Director Suby Kumar		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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The facility has rodent infestation.

The facility is not maintained in a clean and sanitary manner.

The facility is not providing assistance in meeting necessary medical needs of the resident.

The facility is failing to dispense medications as ordered.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto arrives the facility to conduct a complaint investigation regarding allegations that the facility has rodent infestation, the facility is not maintained in a clean and sanitary manner, the facility is not providing assistance in meeting necessary medical needs of the resident and that the facility is failing to dispense medications as ordered. LPA met with Executive Director Suby Kumar. LPA tour room of resident #1 (R1) where mouse droppings were observed. Incident was isolated to R1 room. Facility has an exterminator company that arrives monthly and bi-weekly to treat the facility as well as special instructions pertaining to rodent exclusions. R1's belongings were washed, room clean and treated with carpets professional cleaned. R1 was moved to another room were she will continue her residence. LPA toured the facility to find it clean, free from odors and free from clutter. Staff observed R1, in need of medical attention and addressed this matter appropriately by transporting to a medical facility and providing medical services before returning to the facility. This incident was documented by facility and copy provided to LPA Prieto. R1 is mobile and is witnessed by staff if any needs are required relating to care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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 56-AS-20220912103105

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: 09/14/2022

NARRATIVE

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Resident Services Director (S1) provided a copy of R1's Medication Administration Log (MAR) and upon reviews states that all medications are being dispensed as prescribed.

Based on the information obtained there is not enough evidence that that the facility has rodent infestation, the facility is not maintained in a clean and sanitary manner, the facility is not providing assistance in meeting necessary medical needs of the resident and that the facility is failing to dispense medications as ordered.. Therefore, the allegations that are deemed UNSUBSTANTIATED at this time. A copy of this report was signed by LPA Prieto and Executive Director .

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC9099 (FAS) - (06/04)

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