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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191592479
Report Date: 06/22/2023
Date Signed: 06/22/2023 03:17:19 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2023 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230616134125
FACILITY NAME:ATRIA COVINAFACILITY NUMBER:
191592479
ADMINISTRATOR:ALONDRA FUENTESFACILITY TYPE:
740
ADDRESS:825 W SAN BERNARDINO RDTELEPHONE:
(626) 967-9621
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:90CENSUS: 63DATE:
06/22/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Alondra FuentesTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff failed to provide adequate food service
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Alondra Fuentes and explained the reason for the visit.
The purpose of the visit is to investigate the above allegation.
At today's visit Resident and Staff Roster were submitted.
Special Incident Reports (SIR's) were submitted.
File was reviewed for Resident R 1 and Physician's Report and Emergency ID page were submitted.
Interviews were conducted with Administrator and Director of Culinary Services from 1:30 PM to 2:00 PM.
Tour of the dining room and kitchen was conducted at 2:00 PM.
Interviews were conducted with Residents R 1- R 7 from 2:05 PM to 2:40 PM.
In regards to the allegation Staff failed to provide adequate food service, based on interviews conducted and information gathered Resident's 2-7 all stated that they always get there 3 meals a day and have never missed a meal. Also stated they have never heard of any resident's missing a meal.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
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 2
Control Number 28-AS-20230616134125
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ATRIA COVINA
FACILITY NUMBER: 191592479
VISIT DATE: 06/22/2023
NARRATIVE
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Stated that if not in dining room they will come and find you.
Said there are always choices and no one has ever been denied food.
Interview with Resident R 1 who did not want to speak stating the facility is still providing sustenance and a roof over his head.
Interviews with staff who stated that R 1 will receive the same meals as all resident's which is the Special of the Day. LPA observed menu posted with Special of the Day which included choices.
Staff also stated that R 1 will bring numerous glasses and bottles of water to room and also bowls of ice cream. LPA observed picture of melted ice cream and glasses of water and juice.
Staff stated that gnats would be around the glasses so they would reduce the amount of water and glasses in R 1's room, but meals were always the same as all resident's.
Facility submitted Special Incident Reports(SIR's) related to the hoarding of food and R 1's pushing staff when they tried to bring back the surplus amount of glasses.
Tour of the dining room was done and LPA observed a balanced supply of vegetables, dairy, beef, pork and chicken.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2