366400985-2-7-2024-18-AS-JDHS-D2WQXF-20240229113327

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366400985
Report Date: 02/07/2024
Date Signed: 02/07/2024 09:48:16 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
12/15/2020 and conducted by Evaluator Kathleen Banrasavong

COMPLAINT CONTROL NUMBER: 18-AS-20201215113529

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: 83	DATE:	02/07/2024
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Resident Service Director, Nicole Stinson		TIME COMPLETED:	10:02 AM

ALLEGATION(S):

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Staff are not adhering to the resident's doctor's order.
Staff are not meeting the needs of the resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to deliver findings on a complaint investigation regarding the allegation listed above. LPA met with Resident Service Director, Nicole Stinson and explained the purpose of the visit and the elements of the allegation. LPA Banrasavong conducted the investigation which consisted of observations, interviews with staff members and residents, and record review.

On 12/15/2020, Community Care Licensing (CCL) received a complaint that alleged staff are not adhering to the resident's doctor's order and staff are not meeting the needs of the resident. In regards to the allegations that the staff are not adhering to the resident’s doctor’s orders, it was alleged that R1 was given an order for Intravenous to be given to R1 due to dehydration and diarrhea. During the course of the investigation, LPA reviewed interviews from 2020 with Resident 1 (R1).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

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 3

Control Number 18-AS-20201215113529

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATRIA DEL REY	FACILITY NUMBER: 366400985
	VISIT DATE: 02/07/2024

NARRATIVE

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R1 stated she provided the orders and prescriptions to Staff 1 (S1). S1 is no longer an employee at the facility and was unable to interviewed. During the initial complaint visit on 12/24/2020, the doctor’s order was not obtained. LPA Banrasavong asked the current Executive Director, Subashani Kumar, if the facility retained doctor’s orders for the Intravenous Therapy (IV), for R1. Kumar stated that she could not provide those documents to the LPA, because the document was not retained in R1’s files. It was also advised that there were no records for Resident #1 on the facility database. Executive Director, Kumar further stated that the facility, does not have a registered nurse who works at the facility. Therefore, an appropriate skilled professional was not readily available to assist R1. Staff 2 (S2), who was a staff member during the 2020 year, indicated that during the 2020 year, Covid protocols were being implemented. The facility offered to have R1 get sent out to the emergency room to get Intravenous therapy, but R1 refused. This information was documented in R1’s notes dated 12/15/2020 and 12/16/2020.

In regards to the allegation that staff are not meeting the needs of the resident, it was stated by R1 that R1 made the request for facility staff to administrate the IV, however there were no doctor’s order that were able to be obtained during the course of this investigation. During the investigation, it was revealed that the facility stated they were not going to administer the IV solution due to what the Executive Director stated was Licensing’s regulations. The alternative solution presented to R1 was to have the resident leave the facility and get IV administer at the hospital. R1 refused to go to the hospital due to the Covid restrictions at the time of the complaint. This information was documented on the Resident #1s notes on 12/15/2020.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20201215113529

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ATRIA DEL REY	FACILITY NUMBER: 366400985
	VISIT DATE: 02/07/2024

NARRATIVE

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Based on LPA’s observations and interviews which were conducted and record review(s), the above allegation(s) is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report, along with appeal rights was given to the Resident Service Director, Nicole Stinson as evidenced by her signature.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC9099 (FAS) - (06/04)

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