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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600352
Report Date: 02/02/2023
Date Signed: 02/02/2023 05:13:05 PM


Document Has Been Signed on 02/02/2023 05:13 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: 123DATE:
02/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Jeffrey Freeth, Assistant Executive DirectorTIME COMPLETED:
02:35 PM
NARRATIVE
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On February 2, 2023 at 1:40PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a case management visit. This is a follow-up visit pertaining to a questionable death of a resident who passed away on 8/31/2022. Staff failed to adequately supervise resident, leading to him ingesting chemical substances which ultimately caused his death. LPA met with Jeffrey Freeth, Assistance Executive Director and explained the reason for the visit. During delivery of findings Assistance Executive Director, Jeffrey Freeth, requested Jay Thomas, Assistant General Counsel for Atria to listen to reading of report via telephone.

The Department’s investigation included but was not limited to interviews with former and current staff, witnesses, residents, and the collection and review of records from the facility, Walnut Creek Police Department, Contra Costa Fire Protection District and John Muir Medical Center.

R1 was admitted to the facility on 8/28/2021. It was noted on R1’s pre-placement appraisal, dated 8/20/2021, that R1 was an elopement risk and therefore, one staff must be always present. Resident notes maintained by the facility indicate that R1 exhibited wandering behavior on November 17, 2021, November 30, 2021, January 19, 2022 and February 21, 2022. These behaviors included exiting to the parking lot looking for his car. On January 12, 2023, during interview S3, S4, S5, S6 and S7 staff admitted having knowledge of R1’s AWOL behavior and that he always required supervision.

Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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
VISIT DATE: 02/02/2023
NARRATIVE
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Continued from LIC809.

Based on interview and documentation, on August 23, 2022, R1 wandered into the dining room before midnight and staff (S1) was mopping; Staff (S2) brought him back to his room and S2 shut the dining room door and turned off the lights. Approximately a half hour later, R1 was found sitting in the dining room with a plate of S2’s lunch consisting of steak strips and ‘Flamin ‘Hot Cheetos. R1 vomited and coughed up food before telling S2 that he had been poisoned. Record review and staff interviews indicate R1 had history of wandering around the facility at various times of the day.


On September 30, 2022, camera footage from August 23, 2022, the day of the incident, was reviewed which showed a door to the dining room was open with the lights turned on. Staff (S2) stated during interview she did not know how R1 got inside the dining room because the doors were closed but S2 could not recall if the doors were locked. The kitchen, inside the dining room was unlocked which is against Atria’s policy. The kitchen stored some cleaning supplies in the shelf underneath the kitchen counter. These included, Cleaning Spray and Ecolab 14 Plus Antibacterial All-Purpose Cleaner. Further review of the video footage showed S2 leaving R1 unsupervised as she went to get a mop or broom to clean up in the dining room. R1 was transported to hospital at or around 12:31am where he underwent an endoscopy after failing a swallow test and passed away on August 31, 2022. The autopsy revealed injuries to R1’s mouth, larynx, esophagus, and stomach, consistent with drinking an alkaline substance.

Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
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
VISIT DATE: 02/02/2023
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Continued from LIC809C.

Based on the evidence obtained, it is substantiated that staff failed to adequately supervise resident (R1) leading to him ingesting a chemical substance on August 23, 2022.

Deficiencies are cited under California Code of Regulations, Title 22, Division 6, follows on LIC809D. An immediate civil penalty is issued for $500. Civil penalty determination related to death of resident is pending.

A Non-Compliance Conference (NCC) will be scheduled at a later time.

Exit interview conducted. Appeal Rights 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: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/02/2023 05:13 PM - It Cannot Be Edited

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: 02/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2023
Section Cited

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87705 (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication... and toxic substances ... cleaning supplies and disinfectants. This requirement was not met as evidence by:
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Licensee will submit to licensing a comprehensive plan to include routine inspections of toxic chemicals to ensure they are inaccessible to residents and develop a system to document such inspections have been completed.
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Based on the investigation, licensee did not comply with section cited above and failed to properly supervise R1 as required. This resulted in R1 ingesting chemicals and ultimately passing away which poses an immediate health and safety risk for residents in care.
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Type A
02/03/2023
Section Cited

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87411 (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care... Additional staff shall be employed as necessary... house cleaning, laundering... The licensing agency may require any facility to provide additional staff......This requirement was not met as evidence by:
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Please see above.
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Based on the investigation, licensee did not comply with section cited above and failed to properly supervise R1 as required. This resulted in R1 ingesting chemicals and ultimately passing away which poses an immediate health and safety risk for residents in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4