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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600353
Report Date: 01/04/2023
Date Signed: 01/04/2023 05:05:18 PM


Document Has Been Signed on 01/04/2023 05:05 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 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:
01/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Rosario Holandez, Community Business DirectorTIME COMPLETED:
05:45 PM
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On 01/04/2023, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Case Management Inspection concerning an Unusual Incident Report (UIR) about a missed prescription for resident R1 on 12/30/2022. Upon entry, LPA explained the purpose of the visit and met with Rosario Holandez, Community Business Director.

The LPA interviewed Staff Member S1 who was the staff member who had originally reported the incident. Based on what S1 reported, the facility had reacted quickly enough that the medication did arrive in time for R1 to take her medication on the day she was scheduled to receive it.

No citations were issued.

Exit interview conducted and copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
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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