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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600352
Report Date: 12/18/2020
Date Signed: 12/18/2020 02:13:09 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/20/2019 and conducted by Evaluator Bennett Fong
COMPLAINT CONTROL NUMBER: 15-AS-20191220150824
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
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jennifer CoonsTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident Sustained Injury While in Care
Staff Failed to Seek Medical Attention in a Timely Manner
INVESTIGATION FINDINGS:
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On 12/18/20 at 1:15 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 an in-person visit to the facility was not possible. The visit was conducted by telephone.

During investigation, the Department interviewed several witnesses, and reviewed multiple documents & photos. It was observed that a photo of R1s right foot illustrated dark bruising at the joints of the right foot and toes and that the camera provided a time and date stamp confirming the subject time period. A caregiver reported observing the bruising and hospital records from a presentation shortly after the photo was taken indicated that R1 had a contusion at the right foot. The facility denied knowledge of or having observed the injury.

The Department has investigated these allegations and based upon LPA observations, interviews conducted, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are determined to be Substantiated.

Continued on 9099C...
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20191220150824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/18/2020
NARRATIVE
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Deficiencies cited per Title 22 California Code of Regulations and listed on LIC 9099-D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted and a copy of this report emailed to Administrator.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20191220150824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
12/21/2020
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided. This requirement was not met as evidenced by: LPAs observed a color photo time/date stamped within subject time period illustrating an injury and confirmed by hospital record.
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By the POC date, facility will submit proof of in-house training of all care staff regarding ADL assistance and observation of resident changes.
Type B
01/01/2021
Section Cited
CCR
87464(f)(6)
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Basic Services - Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by: LPAs observed that a photo of R1s, time and date stamped with the subject time period, illustrating an injury and confirmed by hospital record, but staff
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By the POC date, facility will submit to CCL a plan for ensuring that residents are observed for injuries and provided timely medical attention.
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failed to observe the condition and no evaluation was performed.
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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
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/20/2019 and conducted by Evaluator Bennett Fong
COMPLAINT CONTROL NUMBER: 15-AS-20191220150824

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
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Jennifer CoonsTIME COMPLETED:
12:26 PM
ALLEGATION(S):
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Resident was locked in a restroom for a long period of time
Facility is unsanitary
Staff failed to respond to resident's call button in a timely manner
Staff failed to meet resident's hygiene needs
Staff failed to provide a safe environment for resident
Staff illegally evicted resident
INVESTIGATION FINDINGS:
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On 12/18/20 at 1:15 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 perform this visit in person. The Visit was conducted by telephone

The Department conducted an investigation into the above allegations, speaking with multiple witnesses, and reviewing multiple documents and photographs. The facility reported having responded to R1s call button from a common bathroom, but that R1 had locked the door from the inside. This could not be disproven. Neutral witnesses reported no egregious sanitation issue. Photographs from RP were insufficient to determine where they were taken, what was represented, nor whether they illustrated an egregious sanitation deficiency. Witness information was insufficient to determine that R1s grooming and hygiene needs were not being met. A 30 day letter was issued for incidents between R1 and other residents. Although there is dispute regarding the circumstances of the events, information obtained indicated that they did happen.

Continued on 9099A-C ...
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20191220150824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/18/2020
NARRATIVE
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The Department has investigated the above allegations and based upon multiple witness interviews, document and photo reviews, and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are Unsubstantiated.
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
LIC9099 (FAS) - (06/04)
Page: 1 of 2