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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600352
Report Date: 01/12/2023
Date Signed: 01/12/2023 04:11:33 PM


Document Has Been Signed on 01/12/2023 04:11 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: DATE:
01/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Jeffrey Freeth, Assistant Executive DirectorTIME COMPLETED:
04:15 PM
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On 1/12/2023 at 2:25PM Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding a prior incident that was reported to CCLD. LPA met with Jeffrey Freeth, Assistant Executive Director and explained the reason for the visit.

During visit LPA interviewed five (5) staff and collected the staff schedule for memory care. Interviews were to gather information regarding a prior incident.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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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