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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600353
Report Date: 08/17/2021
Date Signed: 08/17/2021 10:00:22 AM



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
06/22/2021 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20210622140830
FACILITY NAME:ATRIA VALLEY VIEWFACILITY NUMBER:
075600353
ADMINISTRATOR:KELLI L GREENEFACILITY TYPE:
740
ADDRESS:1228 ROSSMOOR PKWYTELEPHONE:
(925) 937-7300
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:153CENSUS: 102DATE:
08/17/2021
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Kelli Greene, Executive DirectorTIME COMPLETED:
10:05 AM
ALLEGATION(S):
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Resident was provided services without Resident Representative's approval.

Resident Representative was not allowed to participate in the planning of resident's care.

Staff did not provided a copy of the care plan to Resident's Representative.
INVESTIGATION FINDINGS:
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On 8/17/2021 at 09:35AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to deliver complaint findings for the above allegations. LPA met with Kelli Greene, Executive Director, and explained the reason for the visit.

During the course of investigation, LPA interviewed staff, witnesses, obtained and reviewed staff roster, residents' roster, and resident's file including physician's reports, functional needs assessment, and incident reports. Interviews with witnesses and staff indicated that R1 could make her own decisions and that R1 contacted the agency for a private care person. Documentation indicated that the functional needs assessment was emailed twice to W1.

Continued on LIC9099C.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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-20210622140830
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 VALLEY VIEW
FACILITY NUMBER: 075600353
VISIT DATE: 08/17/2021
NARRATIVE
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Continued from LIC9099.

This agency has investigated the complaint on the above allegations, we have found that the complaint was UNFOUNDED, meaning that the allegations was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

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: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2