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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600352
Report Date: 01/11/2024
Date Signed: 01/11/2024 04:08:09 PM


Document Has Been Signed on 01/11/2024 04:08 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



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: 128DATE:
01/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director (ED) Kelli GreeneTIME COMPLETED:
04:15 PM
NARRATIVE
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On 1/11/2024 at 1:00 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to: (1) deliver updated license that includes probationary status in the comments section of the license and (2) to conduct the initial inspection of the facility after the stipulation went into effect 11/29/2023. Upon arrival, LPA stated the purpose of the visit to Executive Director (ED) Kelli Greene.

During the visit, the LPA delivered the updated license to the ED, who replaced the existing license on the wall. The LPA and ED toured the facility. During the tour, the LPA observed: (1) stipulation posted in a conspicuous place, (2) kitchen and dining area signage posted that no food or beverage containers shall be used for any other purpose than food or beverage containment, and (3) Life Guidance was staffed with 4 direct caregivers for 30 residents, within the 1 staff to 8 resident ratio for day and afternoon/evening shifts and 4 overnight shift staff scheduled, all within the required ratios from the stipulation.

ED and LPA reviewed documents pertaining to the stipulation requirements. The LPA verified that every resident and/or responsible party had acknowledged receipt of a copy of the stipulation. The LPA confirmed that all required staff and administrator training had been completed by every administrator and staff member. The LPA also verified that a Quality Evaluation Committee (QEC) had been formed with members as per the stipulation, a Hazardous Materials and Policies and Procedures Manual had been created by the QEC, the first quarterly QEC audit had been completed in December of 2023, an audit report had been completed within 14 days of that audit, and that a copy of that report was provided to the Department within 14 days.

No citations issued during visit.

Exit interview conducted and a copy of this report provided to ED via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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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