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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600352
Report Date: 03/07/2023
Date Signed: 03/07/2023 03:33:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/23/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20210323144314
FACILITY NAME:ATRIA WALNUT CREEKFACILITY NUMBER:
075600352
ADMINISTRATOR:COONS, JENNIFERFACILITY TYPE:
740
ADDRESS:1400 MONTEGOTELEPHONE:
(925) 938-6611
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:200CENSUS: 127DATE:
03/07/2023
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Jeffrey Freeth/Assistant Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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- Resident (R1) sustained a fractured leg while in care.
- Resident (R1) sustained multiple falls while in care.
- Resident (R1) developed pressure injury while in care.
- Unlawful eviction.
- Facility does not have sufficient staffing to meet resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Assistant Executive Director (AED) Jeffrey Freeth, and informed the purpose of visit.

On 3/24/21 the Department obtained and reviewed copies of the resident roster; staff schedule; R1s medical records; R1s Admission Agreement; the LIC601 Identification and Emergency Information; R1s physician’s report; R1s pre-placement appraisal; incident reports pertaining to R1; progress notes for R1; R1s hospice pre-admission evaluation. On 4/8/21, the Department interviewed the RP and W1; on 6/1/21, the Department interviewed W2; on 6/2/21 the Department interviewed S1, S2, S8 and PC; on 6/16/21 the Department interviewed S3, S4, and S5; and on 6/25/21 the Department interviewed S6.

......continued on 9099C (page2)
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 9
Control Number 15-AS-20210323144314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/07/2023
NARRATIVE
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Page 2

Allegation: Resident (R1) sustained a fractured leg while in care.
On 3/27/21, the Department obtained and reviewed R1s pre-placement evaluation which indicated that R1 was frail with slow gait, and unable to walk without assistance, and determined to be non-ambulatory – dated 5/15/15. On 4/12/21, the Department reviewed and obtained medical records, and the facility’s progress notes for R1 indicating that R1 fell, sustained a head strike, and a broken hip on 7/25/15 while in the facility’s care. There was no record of staff providing assistance, and no incident report was provided to Community Care Licensing (CCL).

Allegation: Resident (R1) sustained multiple falls while in care.
On 3/24/21, the Department reviewed the pre-placement appraisal which indicated R1 was frail with slow gait, unable to walk without assistance, and determined to be non-ambulatory. On 4/8/21, the Department interviewed RP and W1, who reported that beginning in 2015, R1 had experienced numerous falls with injuries. On 6/2/21, the Department interviewed S1 and S2 who confirmed that R1 had experienced a number of falls. On 4/12/21, the Department obtained and reviewed R1s medical records, and on 7/9/21 obtained additional progress notes, indicating that R1 had fallen, struck her head and sustained a fracture to the hip while ambulating in the dining room; that on 3/8/17, R1 was physically declining; that on 8/24/17, R1 experienced a fall and sustained a broken wrist; that on 8/23/18 R1 was running into doors and sustaining bruising; that on 7/1/19 R1 experienced a fall; that on 10/2/19 R1 experienced a fall and sustained a hematoma under the right eyebrow. Furthermore. incident reports from the facility indicated that R1 had experienced additional falls on 6/8/15 and 2/9/16. On 3/24/21, the Department obtained and reviewed R1s Needs and Services Plan dated 3/29/21 that indicated R1 required interventions to decrease the fall risk; however, it does not provide detail as to the specific interventions required. Per the interviews with S3, S4, S5, and S6 with none describing the interventions that R1 needed in order to decrease fall risk, nor what interventions they provided. Furthermore, they illustrated minimal understanding of what care was to be handled by staff, Home Health, and a private caregiver.

.......continued on 9099C (page 3)

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
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 15-AS-20210323144314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/07/2023
NARRATIVE
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Page 3

Allegation: Resident (R1) developed pressure injury while in care.
Per the Department’s review of R1s pre-placement appraisal, R1 was admitted to the facility in 2015 without pressure injury. Review of the resident’s file showed that R1 was admitted to hospice on 7/20/19 for managing end of life general needs. On 5/13/20 Hospice began treating a pressure ulcer at the sacrum which developed into a Stage 3 on 2/19/21 and unstageable by 3/5/21; on 2/1/21 began treating a Stage 2 pressure injury at the coccyx that developed into a Stage 3 on 2/16/21; and a Stage 4 at the right knee on 3/26/21. During interviews with S1, S2, S4, and S5, staff stated having knowledge of some wounds but not others and had no knowledge of their status – reporting that it was the responsibility of hospice. Per those same interviews and the one with W2, it was known that R1s skin condition was fragile and multiple skin tears had developed. None could explain how the skin tears had happened. Review of the Needs and Services of 3/29/21 does not address skin tears, pressure injuries, and interventions such as repositioning. The care staff exhibited little knowledge of interventions to prevent skin tears and pressure injuries for R1.

Allegation: Unlawful eviction.
The facility issued a 30-day Notice of Eviction because the facility is no longer an appropriate setting for R1 for reasons which includes R1’s physician order for R1 to be on a pureed diet. Per records review, R1 was admitted to the facility already on a pureed diet.

Allegation: Facility does not have sufficient staffing to meet resident's needs.
Per the interviews with S1, S2. S3 and S4; and PC, the facility is short of staff. Furthermore, the PC reported that there were few staff observed during December 2020 and January 2021. Per the interview with FM there was an instance where staff did not respond to a call for assistance for 15 minutes.


........continued on 9099C (page 4)
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
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 15-AS-20210323144314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/07/2023
NARRATIVE
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Page 4

Based on records review and interviews, the preponderance of evidence standard is met, therefore, the above allegations are substantiated.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099Ds. Civil penalties are assessed. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

Deficiencies and plan and proof of corrections were discussed.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessments, 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
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 15-AS-20210323144314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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)
Deficiency Dismissed
Type A
03/08/2023
Section Cited
HSC
1569.269(a)(5)
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§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.
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R1 is no longer at the facility.

AED to in-service the staff, and submit copy of training topic with attendees signatures by 3/08/23.

A $500.00 civil penalty is assessed.

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-This is requirement is not met as evidenced by:
-Based on records review, the licensee did not comply with the section above for R1 sustaining fracture which posed immediate health and personal right risks to person in care.
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Request Denied
Type A
03/08/2023
Section Cited
CCR
87464(f)(1)
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87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
-This is requirement is not met as evidenced by:
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AED to add to in-service training of staff, and submit copy of training topic with attendees signatures by 3/08/23.

A $500.00 civil penalty is assessed.
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-Based on records review and interviews, the licensee did not comply with the section above for R1 sustaining injuries such as broken hip, bruising, broken wrist and hematoma which posed immediate health and personal right 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
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 15-AS-20210323144314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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)
Deficiency Dismissed
Type A
03/08/2023
Section Cited
HSC
1569.269(a)(5)
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§1569.269 Enumerated rights severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.


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R1 is no longer at the facility.

AED to in-service the staff, and submit copy of training topic with attendees signatures by 3/08/23.

A $500.00 civil penalty is assessed.
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-This requirement is not met as evidenced by:
- Based on records review and interviews, the licensee did not comply with the section above for R1 sustaining pressure injuries which posed immediate health and personal right risks to person in care.
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Request Denied
Type B
03/21/2023
Section Cited
CCR
87224(a)
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87224 Eviction Procedures
(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph(4) ...........
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R1 is no longer at the facility.

AED to read the Regulations and by 3/21/23, submit a self-certfication indicating it will be followed accordingly.
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-This requirement is not met as evidenced by:
-Based on interviews and record review, the license did not comply with the section above for issuing 30-day eviction for R1 for reason that R1 is on pureed diet which posed a potential personal rights risk 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
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 15-AS-20210323144314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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)
Deficiency Dismissed
Type B
03/21/2023
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General: (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 as required....
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AED to submit an LIC500 Personnel Report and staff schedule for monring, afternoon and NOC shifts by 3/21/23.
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-This requirement is not met as evidenced by:

-Based on records review and interviews, the licensee did not comply with the section above for short staffing which posed potential safety and personal right risks 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: 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
LIC9099 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/23/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20210323144314

FACILITY NAME:ATRIA WALNUT CREEKFACILITY NUMBER:
075600352
ADMINISTRATOR:COONS, JENNIFERFACILITY TYPE:
740
ADDRESS:1400 MONTEGOTELEPHONE:
(925) 938-6611
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:200CENSUS: 127DATE:
03/07/2023
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Jeffrey Freeth/Assistant Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff did not provide resident's authorized representative with a copy of the resident's records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Assistant Executive Director Jeffrey Freeth, and informed the purpose of visit.

It was alleged that facility staff did not provide resident's authorized representative with a copy of the resident's records. On 2/07/23, R1’s responsible person (FM) was interviewed who stated the records that were not provided were medical and medication records, and that FM will provide more information. Follow-up calls were made, and the Department was not able to obtain additional information. On 2/15/23, the previous Executive Director (EDF) was interviewed. EDF was the Executive Director at the time complaint was received. EDF stated all the documents requested were provided to the responsible person.


....continued of 900C (page 2)
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 15-AS-20210323144314
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/07/2023
NARRATIVE
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Page 2

Based on information obtained, the allegation is closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted 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
LIC9099 (FAS) - (06/04)
Page: 9 of 9