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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600352
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:06:29 PM


Document Has Been Signed on 11/29/2022 02:06 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: 128DATE:
11/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:AED Jeff FreethTIME COMPLETED:
02:20 PM
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On 11/29/2022, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced Case Management visit. LPA met with Associate Executive Director (AED) Jeff Freeth in his office and explained the reason for the visit.

The first topic covered was updating the facility's Emergency and Disaster Plan (LIC 610E) from the 2003 version to the 2019 version. The AED will replace the 2003 version with the 2019 version in the facility's Emergency and Disaster binder and send a copy of the updated LIC 610E to the Regional Office (RO) by 12/06/2022.

The second topic covered was reporting Unusual Incidents to the RO in a timely and complete manner. The Unusual Incident Reports (LIC 624s) sent on 11/19, 20, 21, and 23 concerning residents R1, R2, R3, R4, and R5 were sent within 7 working days. However, the RO was not informed of those unusual incidents within 1 working day. Further, the LIC 624 reports were incomplete. Though the residents had been admitted into a hospital, information was missing on the medical treatment received, action taken, follow up, or anticipated results.

The AED now understands what the facility is required to do when an unusual incident occurs. He told the LPA that he will now send an email to the general email for the RO within 1 working day. Further, facility staff will make use of the 7 days to gather additional details. The LIC 624 reports will then include details on hospital medical treatment received, action taken, follow up, and anticipated results.

No citation was issued during the inspection.

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: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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