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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600352
Report Date: 03/07/2023
Date Signed: 03/07/2023 03:57:59 PM


Document Has Been Signed on 03/07/2023 03:57 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: 127DATE:
03/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Jeffrey Freeth/Assistant Executive DirectorTIME COMPLETED:
04:00 PM
NARRATIVE
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During investigation of complaint (Complaint Control # 15-AS-20210323144314) and upon review of documents and interviews, the Department learned that the facility failed to submit reports for resident's (R1) fall where R! sustained injury in 2015.

The Department also learned from the resident’s responsible person (FM) that there was an old mattress in R1’s room for over a year and was not removed until March 2021. Staff (MCD) was interviewed who acknowledged that the mattress was in R1’s room for about 3 weeks before it was discarded,

On this day, March 7, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced. LPA met with Assistant Executive Director (AED) Jeffrey Freeth, and informed the reason for visit. LPA discussed the above.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction due datse may result in civil penalties.



Deficiencies and plan and proof of corrections were discussed with Jeffrey Freeth.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
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 03/07/2023 03:57 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: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2023
Section Cited

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87211 Reporting Requirements
(a) :(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified,,,(D) Any incident which threatens the welfare, safety or health of any resident,
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R1 is no longer at the facilty.

AED will in-service the staff, and in the future, ensure that reports are submitted accordingly.. Proof to be submitted by 3/21/23.
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-This requirement is not met as evidenced by:
-Based on records review and interview, the licensee did not comply with the section above for not submitting incident report for R1 which posed potentia personal right risk to person in care.
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Type B
03/21/2023
Section Cited

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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AED to add to ln-service the staff and submit copy of training topic with attendees signatures by 3/21/23.
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-This requirement is not met as evidenced by:
-Based on interviews, the licensee did not comply with the section above for having an old mattress sitting in resident's room for certain period of time which posed potential safety and personal rights risks to person 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2