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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200326
Report Date: 07/11/2022
Date Signed: 07/11/2022 01:19:11 PM


Document Has Been Signed on 07/11/2022 01:19 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 PARK OF LAFAYETTEFACILITY NUMBER:
079200326
ADMINISTRATOR:QUINLAN-TUDDA, BARBARAFACILITY TYPE:
740
ADDRESS:1545 PLEASANT HILL RDTELEPHONE:
(925) 932-9910
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:130CENSUS: 88DATE:
07/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Barbara Tudda, Executive DirectorTIME COMPLETED:
01:25 PM
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On 07/11/22 at 11:55 AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving self-report SOC341 dated 06/03/22 and incident dated 6/27/22 submitted to CCLD. LPA explained the purpose of the visit with Executive Director (ED).

Self-report SOC341 regarding physical interaction between 2 residents. Based on record review and interview, both subjected residents (R1 & R2) are in memory care unit, they were separated and redirected away in time manor, and monitored by staff frequently. No injury was observed to both residents after incident occurred. Residents' physician, responsible party and ombudsman were notified. Similar incidents have not been repeated since then.

Self-report incident regarding resident developed wound while in care. Based on record review and interview, a assigned wound care nurse has been monitoring and caring resident R3's wound. When R3's wound was noticed getting worse, R3 was transported to Skill Nursing Facility for wound treatment and has not returned to facility as of the date of LPA visit.

LPA obtained residents' physician's reports, care notes, and needs and services plans during visit.

Exit interview conducted with ED, and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
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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