075600353-4-29-2024-15-AS-KHOS-D5YG8V-20240606050747

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075600353
Report Date: 07/26/2023
Date Signed: 04/29/2024 04:38:30 PM

Unsubstantiated

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
07/18/2023 and conducted by Evaluator James Sampair

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230718113231

FACILITY NAME:	ATRIA VALLEY VIEW		FACILITY NUMBER:	075600353
ADMINISTRATOR:	KELLI L GREENE		FACILITY TYPE:	740
ADDRESS:	1228 ROSSMOOR PKWY		TELEPHONE:	(925) 937-7300
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94595
CAPACITY:	153	CENSUS: 95	DATE:	07/26/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Administrator Kawana Anthony		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff does not assist resident when needed.
Staff disturbs resident’s sleep.
Staff does not treat resident with respect.
Resident’s toilet is in disrepair.
Staff does not empty resident’s trash receptacles.

INVESTIGATION FINDINGS:

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On 07/26/2023 at 2:30 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to continue the complaint investigation of the allegations above. LPA informed Administrator (ADM) Kawana Anthony of the reason for the visit.

During the investigation, the LPA interviewed 3 residents, complainant, the ADM, and reviewed facility and resident records. Listed below are the allegations and a brief explanation of the evidence upon which the finding was based:

Staff does not assist resident when needed.
Based on LPA observations, record reviews, an interview with R1, interviews with 2 other residents receiving the same level of care, and the ADM, the LPA found that the staff members are providing assistance to R1 at a level that surpasses that for which she pays.

(Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230718113231

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 VALLEY VIEW	FACILITY NUMBER: 075600353
	VISIT DATE: 07/26/2023

NARRATIVE

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(...Continued from LIC9099)

Staff disturbs resident’s sleep.
Based on LPA observations, record reviews, an interview with R1, and the ADM, the LPA found that the staff members are providing assistance in accordance with the scheduled times in her plan of care.

Staff does not treat resident with respect.
Based on LPA interview with R1, LPA's observations of staff interactions with other residents, interviews with 2 other residents receiving the same level of care, and the ADM, the LPA found that there was no evidence to support that staff members are intentionally treating the resident disrespectfully.

Resident’s toilet is in disrepair.
Based on LPA observation of the toilet, it is fully functional.

Staff does not empty resident’s trash receptacles.
Based on LPA observations, record reviews, an interview with R1, and the ADM, the LPA found that the staff members empty the resident's trash receptacles for R1 at a level that surpasses that for which she pays.

Although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove them; therefore, the allegations are UNSUBSTANTIATED.

Exit interview was conducted with ADM. A copy of this report was provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

LIC9099 (FAS) - (06/04)

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