<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200326
Report Date: 04/16/2021
Date Signed: 04/16/2021 01:23:38 PM

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 PARK OF LAFAYETTEFACILITY NUMBER:
079200326
ADMINISTRATOR:EDUARDO RANGELFACILITY TYPE:
740
ADDRESS:1545 PLEASANT HILL RDTELEPHONE:
(925) 932-9910
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:130CENSUS: DATE:
04/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kaitlyn Clarey and Margaret HsuTIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/16/2021, Licensing Program Analysts (LPA) Leslie Ibo conducted a Case Management Health with Administrator Kaitlyn Clarey and nurse Margaret Hsu, in relation to the incident report submitted on 4/1/2021, R1 was diagnosed with C-Diff, per facility policy they can’t provide care for resident with c-diff, another incident report R2 was sent to Emergency room for un-stageable wound. LPA explained that due to Shelter in Place Order and directive from management to telework, inspection will be done via phone call.
During the interview with Administrator and Nurse, R1 was sent to skilled nursing for c-diff treatment and back to the facility on 4/4/2021.
R2 has a regular home health nurse visit and wound nurse that is routinely check resident’s both legs, 02/20/2021 wound nurse examined R2’s legs and saw redness on right feet, per facility nurse (Margaret Hsu) it wasn’t reported to her, R2 has a wrapped around on both legs and wound care nurse is the one checking on any signs of wounds , on 03/26/2021 wound care nurse HH1 determined that wound is unstageable. Facility nurse then send out resident to ER for further evaluation. On 04/15/2021 a surgical debridement was done for R2 will be transferred to skilled nursing.

LPA will need to conduct follow up visit, LPA requested for documents such as home health nurse notes for R2. Margaret Hsu agreed to send the requested document via email.

Exit interview conducted. Appeal Rights and a copy of this report emailed.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1