374600344-6-27-2024-08-AS-JLOT-D6PTJM-20240629144635

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374600344
Report Date: 06/27/2024
Date Signed: 06/27/2024 10:06:40 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
02/24/2021 and conducted by Evaluator Nacole Patterson

COMPLAINT CONTROL NUMBER: 08-AS-20210224142320

FACILITY NAME:	ATRIA ENCINITAS NORTH		FACILITY NUMBER:	374600344
ADMINISTRATOR:	MARTINEZ, USBALDO		FACILITY TYPE:	740
ADDRESS:	480 S EL CAMINO REAL		TELEPHONE:	(760) 436-6955
CITY:	ENCINITAS	STATE: CA	ZIP CODE:	92024
CAPACITY:	0	CENSUS: 0	DATE:	06/27/2024
		UNANNOUNCED	TIME BEGAN:	06:00 PM
MET WITH:	Facility Closed- Report Mailed to Last Known Address		TIME COMPLETED:	10:00 PM

ALLEGATION(S):

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Resident sustained a pressure injury while in care
Facility did not assist resident with medical care
Staff do not respond to residents call button

INVESTIGATION FINDINGS:

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The following determination of findings has been made by Licensing Program Analyst (LPA) Nacole Patterson regarding the above allegation. The facility closed on September 21, 2021, and this report was mailed to the last known address on record for the former licensee regarding the findings.

On 2/24/2021 it was alleged that Resident 1 (R1) sustained a pressure injury while in care, facility did not assist R1 with medical care, and staff did not respond to R1's call button. The Department’s investigation consisted of interviews with facility staff, outside sources, and records review.

Regarding the allegation, "Resident sustained a pressure injury while in care", staff and outside source interviews were unable to confirm if a pressure injury existed prior to R1 moving into the facility, after R1 was healing from an injury. Staff members interviewed denied that R1 had a pressure wound during the timeframe of the complaint. Records were not found to corroborate the allegation. R1 was not able to be interviewed due to passing away. (Continued on LIC9099-C p.2)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

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 08-AS-20210224142320

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ATRIA ENCINITAS NORTH	FACILITY NUMBER: 374600344
	VISIT DATE: 06/27/2024

NARRATIVE

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(Continued from LIC9099 p.1)

Regarding the allegation, "Facility did not assist resident with medical care", it was alleged that the Licensee did not ensure a medication order from R1's doctor was received for R1's alleged pressure sore. Outside source interviews revealed that the facility's fax machine may have malfunctioned, causing a miscommunication in the order. Staff interviews did not provide additional information regarding the possible delay in the prescription order. Caregivers interviewed who worked with R1 stated that R1 did not have a pressure sore. No records were found to corroborate the allegation. R1 was not able to be interviewed due to passing away.

Regarding the allegation, "Staff do not respond to resident's call button", it was alleged that R1 waited an hour for assistance after pushing their call button. Outside source interviews advised observations of two staff on the floor during each visit and R1 waiting between 5-20 minutes for assistance without significant delay. Staff interviews consistently stated that the caregivers responded timely to resident call buttons. Staff stated that if the call log showed a resident's call was not cleared timely, it was possibly due to the button being pushed outside of the facility, resulting in staff not being able to clear it, or the pendant malfunctioning. Staff interviews revealed that R1 pushed their pendant excessively and it once broke due to R1 pushing it so many times. In this instance staff were unable to clear the call, and the entry erroneously showed that staff did not respond to the call.

Records review corroborated staff statements that caregivers were timely with their calls, as the call log for February 2021 showed that out of 1,230 calls, less than 1% of the calls were cleared after thirty (30) minutes. No further records were found to provide additional information or confirm that the calls over 30 minutes were actual staff delays.

Records review corroborated staff statements that R1 excessively pushed their pendant, as the call log for March 2021 showed that R1 pushed their call button sixty (60) times within an eight (8) day period, many of the calls containing between 1-4 additional "pushes" within the same call. Three (3) of R1's calls show as "No response time (NRT)" and the longest wait time before staff cleared R1's pendant was 36 minutes. No further records were found to provide additional information regarding the call logs, such as if R1 had left the facility or if their pendant was malfunctioning and unable to be cleared. Due to the lack of additional information, it is not possible to ascertain if the call logs accurately represent resident wait times.
(Continued on LIC9099 p.3)

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210224142320

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ATRIA ENCINITAS NORTH	FACILITY NUMBER: 374600344
	VISIT DATE: 06/27/2024

NARRATIVE

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(Continued from LIC9099 p.2)

Based on interviews and records review, the investigation did not yield sufficient evidence to conclude that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were mailed to the last known address on file for the facility.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024

LIC9099 (FAS) - (06/04)

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