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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374600344
Report Date: 07/22/2022
Date Signed: 07/22/2022 11:52:27 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/04/2022 and conducted by Evaluator Iby Strong
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20220104092308
FACILITY NAME:ATRIA ENCINITAS NORTHFACILITY NUMBER:
374600344
ADMINISTRATOR:MARIANO HERNANDEZFACILITY TYPE:
740
ADDRESS:480 S EL CAMINO REALTELEPHONE:
(760) 436-6955
CITY:ENCINITASSTATE: CAZIP CODE:
92024
CAPACITY:65CENSUS: 0DATE:
07/22/2022
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Executive Director Melissa WatkinsTIME COMPLETED:
11:59 AM
ALLEGATION(S):
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Facility not following infection control procedures.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Melissa Watkins.

On January 4, 2022, Community Care Licensing (CCL) received a complaint alleging facility is not following infection control procedures. During the investigation, LPA Strong and Licensing Program Manager (LPM) John Rante conducted an unannounced inspection of the facility. When the Department arrived at the facility on January 14, 2022 there was no infection control screening at the entrance of the facility, as required by Provider Information Notice (PIN) 21-40-ASC. Additionally, during the facility tour, LPA and LPM witnessed Staff1 (S1) wearing a face mask only covering S1’s mouth. Interviews with staff and the Executive Director revealed that the facility did not have any N95 respirators available for staff to use while caring for COVID19 positive residents. Records collected verified that there were a total 3 COVID19 positive residents and 4 COVID19 positive staff between December 29, 2021 until January 19, 2022.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
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 3
Control Number 08-AS-20220104092308
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: ATRIA ENCINITAS NORTH
FACILITY NUMBER: 374600344
VISIT DATE: 07/22/2022
NARRATIVE
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Based on staff interviews, review of records, and observations, a preponderance of evidence exists to support the allegation that facility staff is not following infection control procedures. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Melissa Watkins, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 01/16) were provided to.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20220104092308
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ATRIA ENCINITAS NORTH
FACILITY NUMBER: 374600344
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/22/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities- (a)(2)To be accorded safe, healthful and comfortable accommodations furnishings and equipment. This requirement is not met as evidence by:
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The Executive Director (ED)will provide LPA with a statement that Pacifica Encinitas North plans to forfeit license by 8/5/2022.
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Based on interviews,record reviews and observations, the licensee did not follow infection control procedures for 35 of 35 residents in care which posed a potential Health, Safety, or Personal Rights risk to persons 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: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3