<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366400985
Report Date: 07/01/2021
Date Signed: 07/01/2021 11:46:56 AM



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
06/11/2021 and conducted by Evaluator Pauline Beschorner
COMPLAINT CONTROL NUMBER: 18-AS-20210611161042
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: 85DATE:
07/01/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Samuel DeGuzmanTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has bed bugs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pauline Beschorner made an unannounced visit to the facility to deliver findings regarding the above allegation. Upon arrival, LPA met with Executive Director Samuel DeGuzman. LPA explained the purpose of the visit and was granted entry into the facility.

The allegation alleges facility has bed bugs. Based on interviews with pertinent witnesses and facility staff interviews revealed R1 was complaining of itching beginning June 1, 2021. A review of documents revealed on June 8, 2021 EcoLab Pest Control came out and provided an overall inspection. The inspection report, notes there was “no evident pest issue found in R1’s room.” On June 9, 2021 bed bugs were observed in R1’s chair and EcoLab Pest Control was called to return to the facility. On June 10, 2021 EcoLab Pest Control confirmed bed bugs were noted in R1’s room and corrected the initial report from the visit on June 8, 2021. EcoLab suggested R1’s room to be taken out of service and the bed bug treatment was performed. The facility and pest control company have been working collaboratively to eliminate the bed bug infestation in R1’s room. During LPA’s initial unannounced visit on 6/16/2021 LPA observed R1’s room and surrounding rooms to
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
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
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
06/11/2021 and conducted by Evaluator Pauline Beschorner
COMPLAINT CONTROL NUMBER: 18-AS-20210611161042

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: DATE:
07/01/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Samuel DeGuzmanTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident room is not maintained clean.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Pauline Beschorner made an unannounced visit to the facility to deliver findings regarding the above allegation. Upon arrival, LPA met with Executive Director Samuel DeGuzman. LPA explained the purpose of the visit and was granted entry into the facility.

The allegation alleges resident room is not maintained clean. Based on interviews with resident (R1), pertinent witnesses and facility staff interviews revealed housekeeping provides housekeeping services one time per week. For R1, housekeeping services are provided on Wednesday’s. Interview with R1 revealed housekeeping will vacuum the floor, clean the bathroom, provide towels if requested, use a feather duster to dust the furniture and tidy up as needed. Due to room being out of service at time of initial investigation LPA is unable to corroborate whether R1’s room was not maintained clean. During the visit conducted on 7/1/2021 LPA observed R1's carpets to be clean and no spider webs present in windows.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20210611161042
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: 07/01/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
alleged violation did or did not occur therefore the allegation is UNSUBSTANTIATED at this time.

An exit interview was conducted, and a copy of this report was provided to Executive Director Samuel DeGuzman, whose signature on this form confirm the receipt of the above-mentioned documents.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20210611161042
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: 07/01/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
be out of service. It should be noted that the surrounding rooms are not occupied and were treated out of precaution. No other bed bugs have been reported in other rooms. This allegation is unfounded at this time as the facility requested the exterminator immediately upon learning of the bed bugs as well as notified state licensing and took precautions to make sure the resident was free of any health and safety concerns.

Based on interviews with facility staff, pertinent witnesses and document review the above allegation isUNFOUNDED, meaning the allegations are false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was reviewed, and appeal rights were provided to Executive Director Samuel DeGuzman, whose signature on this form confirm receipt of the above-mentioned documents.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4