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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600352
Report Date: 12/18/2020
Date Signed: 12/18/2020 02:59:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ATRIA WALNUT CREEKFACILITY NUMBER:
075600352
ADMINISTRATOR:COONS, JENNIFERFACILITY TYPE:
740
ADDRESS:1400 MONTEGOTELEPHONE:
(925) 938-6611
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:200CENSUS: 108DATE:
12/18/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jennifer CoonsTIME COMPLETED:
03:00 PM
NARRATIVE
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On 12/18/20 at 2:00 pm AGPA / Acting LPM Jeremy Fong conducted an unannounced continuing complaint visit, meeting with S1. Due to the State’s current Shelter-in-Place order it was not possible to conduct the visit in person. The visit was conducted by telephone.

While reviewing a separate matter, AGPA / Acting LPM determined that a subject resident was issued a 30 day letter for altercations with other residents (the altercations did occur); however, information obtained indicated that they were not solely due to the subject resident yet it was assumed that this individual was the perpetrator. Additionally, the facility performed an evaluation of the resident shortly before the documented incidents and it was determined that subject resident did not have behavioral concerns.

Deficiency is cited per CCRs Title 22 on the attached 809D form. Failure to submit proof or correction by the POC date and/or the same deficiency occurring within 12 months may result in civil penalties.

Report reviewed with facility and appeal rights provided.

SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ATRIA WALNUT CREEK
FACILITY NUMBER: 075600352
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/01/2021
Section Cited

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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: AGPA observed that subject resident had been subjected to disciplinary action when
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multiple residents were involved in altercations.
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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: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2020
LIC809 (FAS) - (06/04)
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