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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600353
Report Date: 07/28/2023
Date Signed: 07/28/2023 11:19:16 AM


Document Has Been Signed on 07/28/2023 11:19 AM - 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 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: 95DATE:
07/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kwana AnthonyTIME COMPLETED:
11:30 AM
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On 07/28/2023 at 9:00 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to personally deliver findings from complaint 15-AS-20230718113231 to resident R1. LPA stated the purpose of the visit to the front desk person without identifying the identity of R1.

During the visit, the LPA spoke with the initial complainant about the findings. The questions she asked prompted some questions for the LPA to follow up on. For that reason, the LPA interviewed Resident Services Director (RSD) Joann Bustos about the level of care being provided to resident R1. The RSD verified that the services being provided matched those on R1's Plan of Care. LPA then reported back to the Complainant verification that R1 was fully receiving the level of care as written in her Plan of Care.

No citations issued during this visit.

Exit interview was conducted with ADM. A copy of this report was provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
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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