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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366400985
Report Date: 03/14/2022
Date Signed: 03/14/2022 11:13:58 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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/01/2021 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211201102705
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: 81DATE:
03/14/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Erick Romero, Director of Culinary SevicesTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident fell while in care
Rsident sustained injuries while in care
INVESTIGATION FINDINGS:
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On 3/14/22 Licensing Program Analyst (LPA) Shaunte Henry conducted an unuannounced visit for the purpose of delivering the findings to the above allegations. LPA Henry met with Erick Romero, Director of Culinary Sevices.
The investigation, which consisted of observation, file review and interviews revealed the following:
During an interview family, it was reported that Resident 1 (R1) fell in September of 2021 and 11/24/21. R1 was not able to confirm the date of the September fall. During an interview with R1, during the September fall, they were able to get up off of the floor without assistance. R1 did not report the fall to the facility. R1 told a family member that they had fallen. R1's family called the facility on 9/30/21 and told the facility that R1 had a fall some time in September, but they did not have an exact date.
***Continued on 9099C***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
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 5
Control Number 18-AS-20211201102705
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2022
Section Cited
CCR
87411(a)
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PERSONNEL REQUIREMENTS (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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The licensee will review the cited regulation, sign/date and provide a copy to the department by the POC date.
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Based on file review and interviews, R1 sustaind a fall on 9/24/22 and 11/23/21. Both falls resulted in minor injuries. This is a potential health and safety risk to residents in care.
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Type B
03/18/2022
Section Cited
CCR
87468.1(a)(2)
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PERSONAL RIGHTS (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations...
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The licensee will review the cited regulation, discuss with staff the importance of safety regarding residents. Sign/date and provide a copy to the department by the POC date.
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Based on file review and interviews, R1 sustained injuries after a fall in 9/24/21 and 11/23/21. This is a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
12/01/2021 and conducted by Evaluator Shaunte Henry
COMPLAINT CONTROL NUMBER: 18-AS-20211201102705

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:
03/14/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Erick Romero, Director of Culinary SevicesTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not notify resident's authorized representatives of incidents
Resident's ceiling is in disrepair
Staff did not provide basic laundry services for resident.
INVESTIGATION FINDINGS:
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On 3/14/22 Licensing Program Analyst (LPA) Shaunte Henry conducted an unuannounced visit for the purpose of delivering the findings to the above allegations. LPA Henry met with Erick Romero, Director of Culinary Sevices.
The investigation, which consisted of observation, file review and interviews revealed the following:
During an interview with Director Sam DeGuzman, Sam reported that when Resident 1 (R1) fell on 11/23/21, the facility contacted R1's responsible party. R1's resident log confirms this information. The facility was not aware of R1's fall in September of 2021. In regard to the ceiling being in disrepair, Sam stated that a resident above R1, had an accident involving water. Sam stated that since the water went through the floor of the above resident, which was R1's ceiling, the water needed to dry out completely prior to finalizing the repairs. R1's celing was fully repaired on 12/9/21.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20211201102705
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: 03/14/2022
NARRATIVE
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 ***continued from 9099***

The LPA observed the ceiling repairs. Interviews with the director, Staff 1 (S1), R1 was being provided laundry services every Monday.


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

An exit interview was conducted where this report was provided to the director.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 18-AS-20211201102705
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: 03/14/2022
NARRATIVE
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 ***Continued from 9099***

An interview with the facility director, Sam DeGuzman and R1 revealed R1 sustained a fall on 11/23/21, which resulted in a laceration to the left arm. R1's wounds were treated by the on-site nurse as well as urgent care.

Based on LPAs observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 ) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC 9099D, LIC 81 and appeal rights were provided to Erick Romero, Director of Culinary Sevices.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5