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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600352
Report Date: 11/29/2023
Date Signed: 11/29/2023 05:04:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
11/21/2023 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231121171228
FACILITY NAME:ATRIA WALNUT CREEKFACILITY NUMBER:
075600352
ADMINISTRATOR:KELLI GREENEFACILITY TYPE:
740
ADDRESS:1400 MONTEGOTELEPHONE:
(925) 938-6611
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:200CENSUS: 135DATE:
11/29/2023
UNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Administrator Kelli GreeneTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility did not issue a refund to a resident in care.
INVESTIGATION FINDINGS:
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On 11/29/2023 at 8:27 AM, Licensing Program Analyst (LPA) J. Sampair performed an unannounced complaint visit pertaining to the allegation above. The LPA informed the Administrator (ADM) Kelli Greene of the purpose of the visit.

The complaint alleges that the facility did not issue a refund of Resident 1 (R1)'s preadmission fee after departing the facility 08/18/2023. During the review of R1's Resident Account Summary and Admission Agreement, the ADM and LPA discovered a processing error that resulted in the non-payment of the portion of preadmission fee due to R1. To rectify their error, the facility issued a refund of $2,186.63, which was $908.63 more than $1,278.00 required.

The preponderance of the evidence standard has been met, and the allegation is SUBSTANTIATED. One (1) Type-B citation issued (refer to LIC9099-D for details).

Exit interview conducted with ADM and a copy of this report was provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
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 2
Control Number 15-AS-20231121171228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ATRIA WALNUT CREEK
FACILITY NUMBER: 075600352
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2023
Section Cited
CCR
87507(g)(5)(E)2.c.
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Admission Agreements (g) ... shall specify ... (5) Refund conditions. (E) ... 2. ... paid preadmission fees ... shall be refunded ... in the following manner: c. ... at least 40 percent in excess of $500 shall be provided if the resident leaves the facility for any reason during the third month of residency.
This requirement is not met as evidenced by:
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Licensee corrected deficiency during visit by issuing a refund of $2,186.63, which was the Basic Services fee for the 18 days of residency from August 1 to 18 of 2023. That amount was $908.63 more than the $1,278.00 that was due to R1 according to Title 22 Regulation.
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Based on file review, the licensee did not comply with the section cited above. No refund had been issued to Resident 1 for the $1,278 in preadmission fees due, which posed a potential health, safety, or personal rights 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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2