366400985-7-8-2021-18-AS-RLAY-C4VU2H-20210713151158

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366400985
Report Date: 07/01/2021
Date Signed: 07/08/2021 11:10:10 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
05/25/2021 and conducted by Evaluator Pauline Beschorner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210525135840

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: 85	DATE:	07/01/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Samuel DeGuzman		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility does not meet resident's dietary needs
Facility not maintained clean and sanitary at all times
Facility did not ensure that needles and syringes are disposed of properly

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 allegations. LPA met with Executive Director Samuel DeGuzman.

The investigation included interviews with executive director, staff, resident (R1) and record review. The first allegation alleges facility does not meet resident's dietary needs. On October 30, 2020 R1 signed a special diet clarification form that indicated R1 was able to self-manage a special diet and R1's diet should not include any concentrated sweets. A review of R1's physician report reveals R1 is to have a diabetic diet. A review of R1's admission's agreement does not indicate R1 has a special diet. Interviews with executive director and staff revealed a diabetic diet is not offered at the facility but rather limited concentrated sweets are offered. Based on the information provided it is unclear what type of diet R1 is to be on and whether R1 was able to self-manage R1's own diet.

The second allegation alleges facility is not clean and sanitary at all times. LPA observed the facility to be

Unsubstantiated

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)

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
05/25/2021 and conducted by Evaluator Pauline Beschorner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210525135840

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: 85	DATE:	07/01/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Samuel DeGuzman		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility did not arrange medical appointments for resident
Staff did not report resident's change in condition to responsible party

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.

The investigation included interviews with executive director, staff, resident (R1) and record review. The first allegation alleges facility did not arrange medical appointments for resident. Interviews with executive director, staff and R1 revealed, R1 makes all medical appointments. R1’s admission agreement also revealed that R1 was not receiving this service. In September 2020, facility staff made an attempt for R1 to be seen by the facility physician's assistant (PA), as a courtesy. However, R1 refused this visit. Staff periodically performed reassessments on R1. Assessments did not indicate any changes were needed, as to R1’s ability for self-care. When facility was made aware R1 needed to be seen by a podiatrist the facility made arrangements for a podiatrist to come to the facility to assist R1 as soon as the podiatrist was available.

The second allegation alleges staff did not report resident's change in condition to responsible party. Interviews with

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: 06/15/2021

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-20210525135840

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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executive director and staff revealed R1 is R1's own responsible party. A review of R1's Admission's Agreement, and R1's Identification and Emergency Information form corroborates R1 is R1's own responsible party. R1 has signed all documents and there is no information showing R1 has any other responsible party to report change of condition to.

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: 07/01/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20210525135840

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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clean, safe, sanitary and in good repair. LPA observed the housekeeping schedule for R1's room. The resident’s rooms are cleaned based off of the residents Admission's Agreement. R1's admission's agreement states housekeeping will go into R1's room 1 time per week to dust, vacuum, clean the bathroom and provide towels if needed. Due to R1's health diagnosis LPA is unable to corroborate whether R1's room has health hazards that would affect the health and safety of R1.

The third allegation alleges facility did not ensure that needles and syringes are disposed of properly. Interviews with executive director and staff revealed R1 is able to administer R1's insulin shots. Executive Director stated R1 has always taken used syringes to the fire station and recently stopped. The facility provided R1 with a disposable bin to place used syringes in. During interview with R1 LPA observed approximately 5 used insulin needles in a coffee mug. LPA is unable to corroborate when staff started providing the disposable bin and what further steps staff took when R1 would not put used syringes in bin as needed.

Although the above-mentioned allegations may have happened, or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are deemed UNSUBSTANTIATED at this time.

An exit interview was conducted, and a copy of this report was reviewed with and provided to Executive Director Samuel DeGuzman, whose signature on this form confirm receipt of 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: 06/15/2021

LIC9099 (FAS) - (06/04)

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