075600353-10-22-2021-15-AS-KHOS-C86LJ5-20211026084722

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075600353
Report Date: 10/22/2021
Date Signed: 10/22/2021 04:50:16 PM

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
10/13/2021 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20211013102820

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: 104	DATE:	10/22/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Rosario Holandez, Community Business Director		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff spoke inappropriately to resident
Facility did not report suspected abuse in a timely manner

INVESTIGATION FINDINGS:

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On 10/22/21 at 3PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint investigation and met with Community Business Director (CBD). LPA explained the purpose of the visit with CBD and Executive Director (ED) on the phone. ED authorized CBD to act on her behalf and sign the reports.

Allegation: Staff spoke inappropriately to resident
Investigation Finding: Substantiated
During investigation, ED confirmed with LPA that S1 admitted to saying "shut your mouth" to resident (R1) when R1 was sharing personal information about another resident with someone else the weekend of 09/11/21 - 09/12/21. Internal investigation conducted by ED confirmed S1 verbally abused R1 at the facility.

Continued on next page, LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

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-20211013102820

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: 10/22/2021

NARRATIVE

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Allegation: Facility did not report suspected abuse in a timely manner
Investigation Finding: Substantiated
Based on interviews and record reviews, R1 reported the incident to the ombudsman on 09/13/21. On 09/21/21, LPA C Fowler received a faxed SOC341 report from ED stating that the Ombudsman asked the ED to complete an SOC341 while the ED was still in the process of completing the investigation of the incident. LPA confirmed with ED that facility failed to report the suspected elder abuse in a timely manner. ED also told LPA that unusual incident report (LIC 624) was not completed/sent to CCLD regarding the incident.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20211013102820

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/08/2021 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.	1 2 3 4 5 6 7	ED discussed the incident with S1, conducted in-service retraining on 09/23/21 regarding elder abuse. ED agreed to submit to CCLD on or before POC due date
	8 9 10 11 12 13 14	This requirement was not met as evidenced by S1 admitting to verbally abusing R1 which posed a potential health & safety risk to residents in care	8 9 10 11 12 13 14	staff retraining certification from an accredited vendor on elder abuse.
Type B 11/08/2021 Section Cited CCR 87211(b)	1 2 3 4 5 6 7	Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1)	1 2 3 4 5 6 7	ED agreed to submit to CCLD on or before POC due date a self certification that staff will comply with Title 22 Section 87211 reporting requirements regulations.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by SOC 341 not reported in a timely manner which posed a potential health & safety risk to residents in care	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC9099 (FAS) - (06/04)

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