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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600352
Report Date: 09/01/2022
Date Signed: 09/01/2022 03:41:34 PM


Document Has Been Signed on 09/01/2022 03:41 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: 124DATE:
09/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Jeffrey Freeth, Assistant Executive DirectorTIME COMPLETED:
03:45 PM
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On 9/1/2022 at 1:45PM Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 8/24/2022. LPA met with Jeffrey Freeth, Assistant Executive Director and explained the reason for the visit.

The incident that was submitted for R1 occurred on 8/23/2022 where R1 was taken to the emergency room at John Muir Hospital resulting from a choking incident. The facility later submitted a Death Report for R1 on 8/31/2022. LPA met and spoke with Assistant Executive Director to get more information regarding the incidents. Assistant Executive Director stated that he arrived at the facility the morning of 8/24/2022 and was advised about the incident by S2 and S3. Assistant Executive Director stated that staff called the hospital on 8/24/2022 and was told that a series of test were being given. Assistant Executive Director stated staff called the hospital several times after and was advised by hospital staff that the family did not want any information given. Assistant Executive Director stated that the facility was not aware of R1's death until the coroner arrived on 8/31/2022.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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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