366400985-7-1-2021-18-AS-RLAY-C4NSLL-20210706135831

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366400985
Report Date: 07/01/2021
Date Signed: 07/01/2021 10:46:31 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
05/19/2021 and conducted by Evaluator Pauline Beschorner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210519115210

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:	DATE:	07/01/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Samuel DeGuzman		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff are not providing adequate care and supervision to a resident
Staff are not addressing a resident's change in level of care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pauline Beschorner conducted an unannounced complaint visit in order to deliver findings for the above complaint allegation. LPA met with Executive Director Samuel DeGuzman.

This investigation included interviews with executive director, staff, resident (R1) and record review. The first allegation alleges staff are not providing adequate care and supervision to a resident. Interviews with staff revealed R1 is independent and able to care for all activities of daily living (ADL's), personal care and administer all medication. Interview with R1 cooberated this information. Per physician's report R1 is able to administer R1's own medication without assistance, and is able to care for all ADL's.

The second allegation alleges staff are not addressing a resident's change in level of care. Interviews with executive director and staff revealed R1 moved into the facility in April 2020. Reassessments were conducted for R1 May 6, 2020, August 2, 2020, January 27, 2021. and April 23, 2021. The completed reassessments revealed no change of care needed. On May 20, 2021, the facility met with the family for a Care Plan Meeting

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline Beschorner	TELEPHONE: (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)

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Control Number 18-AS-20210519115210

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

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and R1's change of condition was addressed.

This agency has investigated the above mentioned allegations and we have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted, and a copy of this report is being reviewed with and provided to the facility Executive DIrector Samuel DeGuzman whose signature on this form confirms the above-mentioned documents.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline Beschorner	TELEPHONE: (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: 06/30/2021

LIC9099 (FAS) - (06/04)

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