075600352-4-18-2023-15-AS-LHAL-CQZPJV-20230418112209

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075600352
Report Date: 04/18/2023
Date Signed: 04/18/2023 11:22:23 AM

Document Has Been Signed on 04/18/2023 11:22 AM - 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 CREEK		FACILITY NUMBER:	075600352
ADMINISTRATOR:	FREETH, JEFFREY		FACILITY TYPE:	740
ADDRESS:	1400 MONTEGO		TELEPHONE:	(925) 938-6611
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	200	CENSUS: 123	DATE:	04/18/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Kelli Greene, Executive Director		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA). L. Hall conducted a Case Management visit on 4/18/2023. This is a follow up on a case management citation for a questionable death of a resident. LPA met with Kelli Greene, Executive Director and explained the purpose of the visit. On February 2, 2023, the Department concluded a case management investigation and determined that the facility had failed to adequately supervise R1. Per autopsy, R1 had sustained injuries consistent with ingesting a caustic liquid cleaning agent; and expired on August 31, 2022, due to the injuries. It was also determined that the facility failed to have staff with adequate competency to provide the services necessary to meet residents’ needs. The Licensee was cited for violating California Code of Regulations (CCR) Title 22 § 87705(f)(2) – Care of Persons with Dementia, which states in part that “(f) The following shall be stored inaccessible to residents with dementia (2) Over the counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.” In addition, the Licensee was cited for violating California Code of Regulations (CCR) Title 22 § 87411(a) Personnel Requirements, which states in part that “(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

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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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: 04/18/2023

NARRATIVE

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Continued from LIC809.

R1 was admitted to the facility on August 28, 2021. It was noted on R1’s pre-placement appraisal, dated August 20, 2021, that R1 was an elopement risk and therefore one staff person must always be 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 R1’s car. On January 12, 2023, during interviews with staff (S3, S4, S5, S6 and S7), staff admitted to having knowledge of R1’s AWOL behavior and that R1 always required supervision.

Based on interview and documentation, on August 23, 2022, R1 wandered into the dining room before midnight while staff (S1) was mopping the floor; Staff (S2) brought R1 back to R1’s room. S2 shut the dining room door and turned off the lights. Approximately one-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 they had been poisoned. Record review and staff interviews indicate R1 had a 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. S2 stated during an interview that they 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 facility policy. The kitchen stored cleaning supplies on the shelf underneath the kitchen counter. These supplies included Cleaning Spray and Ecolab 14 Plus Antibacterial All-Purpose Cleaner.

Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC809 (FAS) - (06/04)

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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: 04/18/2023

NARRATIVE

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Continued from LIC809C.

Further review of the video footage showed S2 leaving R1 unsupervised as S2 went to get a mop or broom to clean up in the dining room. R1 was transported to hospital at or around 12:31 a.m. where R1 underwent an endoscopy after failing a swallow test and passed away on August 31, 2022. The autopsy report for R1, dated January 23, 2023, revealed caustic injuries to R1’s pharynx, esophagus, and stomach, consistent with the ingestion of a caustic liquid cleaning agent.

Based on observation, interviews, and records review by the Department, it was determined that R1 was not adequately supervised, resulting in R1 being injured and expiring due to the ingestion of a caustic liquid cleaning agent.

At the time of the Case Management visit, an immediate civil penalty of $500.00 was issued. The issuance of an additional civil penalty was still being determined and the licensee was informed that an additional civil penalty might be assessed. The Department has concluded an analysis and has determined that a civil penalty is warranted. Today, 04/18/2023, the Department will be issuing a civil penalty in the amount of $15,000.00 per California Health and Safety Code §1569.49(d) for a violation the Department determined resulted in the death of R1. However, since an immediate civil penalty of $500.00 was previously issued on February 2, 2023, the amount of the civil penalty issued today will be $14,500.00.

Exit interview conducted. Appeal rights and a copy of the LIC 421D were provided. A copy of the report was issued and provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC809 (FAS) - (06/04)

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