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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 05:07:00 PM


Document Has Been Signed on 02/02/2023 05:07 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:
03:35 PM
MET WITH:Jeffrey Freeth, Assistant Executive DirectorTIME COMPLETED:
05:20 PM
NARRATIVE
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On 2/02/2023 at 03:35PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Jeffrey Freeth, Assistant Executive Director and explained the purpose of the visit. During delivery of citation Assistance Executive Director, Jeffrey Freeth, requested Jay Thomas, Assistant General Counsel for Atria to listen to reading of report via telephone

While the Department was conducting a case management visit on 9/1/2022 regarding an incident reported 8/24/2022, LPA L. Hall obtained the appraisal needs and services plan for Resident 1 (R1), which had not been updated since 11/10/2021 or signed by R1's representative.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights 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
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 2


Document Has Been Signed on 02/02/2023 05:07 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 B
02/09/2023
Section Cited

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87463 (c)The licensee shall arrange a meeting with the resident, the resident’s representative... if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first... This requirement was not met as evidence by:
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Administrator agreed to comply with section 87463 and submit a written plan of correction indicating how to prevent this from happening in the future to CCLD by POC date.
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Based on LPAs observation and record review the Licensee did not comply with the section cited above in failing to ensure R1's appraisal needs and services plan was up-to-date, which posed an immediate health and safety risk to persons 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: 2 of 2