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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600353
Report Date: 05/02/2023
Date Signed: 05/02/2023 05:40:23 PM


Document Has Been Signed on 05/02/2023 05:40 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: 101DATE:
05/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Interim Executive Director Kawana Anthony and Resident Services Director (RSD) Joanne BustosTIME COMPLETED:
05:45 PM
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On 05/02/2023 at 3:10 PM, Licensing Program Analyst (LPA) J Sampair arrived unannounced for a visit concerning the gastrointestinal outbreak at the facility with Interim Executive Director (IED) Kawana Anthony. At approximately 3:50 PM, Resident Services Director (RSD) Joanne Bustos joined the meeting and it was after her arrival when they addressed the Unusual Incident Report (UIR) concerning a resident-on-resident fight that was dated 02/08/2023.

The RSD provided an update concerning Resident 1 (R1) who had been reported to have instigated the assault to Resident 2 (R2) as witnessed by Resident 3 (R3). The RSD reported that there had not been any additional incidents involving R1, and that he was scheduled to move out of the facility the following day.

No citations issued during visit.

Exit interview conducted with IED and a 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: 05/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2023
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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