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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600352
Report Date: 09/02/2022
Date Signed: 09/02/2022 04:28:30 PM


Document Has Been Signed on 09/02/2022 04:28 PM - It Cannot Be Edited

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:FREETH, JEFFREYFACILITY TYPE:
740
ADDRESS:1400 MONTEGOTELEPHONE:
(925) 938-6611
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:200CENSUS: 129DATE:
09/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Leasha BrownTIME COMPLETED:
04:45 PM
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On 9/2/2022 at 3:00 PM, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 8/30/2022. LPA met with Resident Services Director (RSD) Leasha Brown and explained the reason for the visit.

The incident that was submitted for R1 occurred on 8/29/2022 where resident R1 was discovered walking unattended outside of the community by one of their bus drivers who picked her up and returned her to the community. LPA met and spoke with RSD to get more information regarding R1, the incident, and the response of the facility to the incident.

The Physician's Report indicated that R1 has a mild case of dementia and that she is able to leave the facility unassisted.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
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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