079200326-4-2-2025-15-AS-YFLS-DFKRZ2-20250409132713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200326
Report Date: 04/02/2025
Date Signed: 04/02/2025 11:03:07 AM

Unsubstantiated

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
06/28/2023 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20230628163332

FACILITY NAME:	ATRIA PARK OF LAFAYETTE		FACILITY NUMBER:	079200326
ADMINISTRATOR:	QUINLAN-TUDDA, BARBARA		FACILITY TYPE:	740
ADDRESS:	1545 PLEASANT HILL RD		TELEPHONE:	(925) 932-9910
CITY:	LAFAYETTE	STATE: CA	ZIP CODE:	94549
CAPACITY:	130	CENSUS: 92	DATE:	04/02/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Kawana Anthony, Operations Specialist		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Lack of care and supervision resulting in resident sustaining serious injury while in care

INVESTIGATION FINDINGS:

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On 04/02/15 at 10:30 am, Licensing Program Analyst (LPA) arrived unannounced to deliver complaint investigation findings for the above allegation. LPA met with Operations Specialist, Kawana Anthony and explained the purpose of the visit.

During the course of the investigation, the Department obtained information, interviewed 4 residents and 8 staff, and reviewed records. The Department obtained the following documents, including but not limited to: Personnel Report (LIC 500), Resident Notes, Preplacement Appraisal, Needs and Services Plan, Visitor Log, Resident Sign in/out Sheet, and Staff Contact Information.

The Department investigated allegation neglect/lack of supervision resulting in resident sustaining serious injury while in care. On 06/04/2023, Resident 1 (R1) exited the facility after a visitor held the front door open for R1.

Continued on 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

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-20230628163332

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 PARK OF LAFAYETTE	FACILITY NUMBER: 079200326
	VISIT DATE: 04/02/2025

NARRATIVE

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...Continued from 9099

According to the incident report dated 6/6/23, R1 was found on the ground in front of community entrance with R1’s chair behind R1 at approximately 3:40 p.m. on 6/4/23. 9-1-1 was called and R1 was transported to John Muir Emergency. According to the triage record dated 6/4/23, the chief complaint was a fall. Triage record indicated that R1 fell out of the wheelchair and was down on the ground with wheelchair on top of R1. R1 was diagnosed with traumatic subarachnoid hemorrhage (HCC) and returned to the facility under Suncrest Hospice on 6/8/23.

On 7/11/23, the Department interviewed 4 staff (S1, S2, S3 and S4) and 4 residents (R1, R2, R3 and R4), and reviewed the facility’s video camera footage. Video camera footage confirmed that an unknown male held the door opened for R1 to exit and R1 was seen leaving the facility lobby and headed to the left of the facility property. Approximately four (4) minutes later, unknown elderly went into the facility and walks to the front desk, then S3 was seen exiting the facility, and other staff were seen responding outside to the left of the facility. The Department attempted to interview R1, but unable to obtain additional information.

On 7/18/23, the Department interviewed 2 staff (S5 and S6). Additionally, interviews with S7 and S8 were conducted on 8/21/23 and 8/23/23 respectively. Although R1’s Physician’s Report dated 5/2/23 indicates R1 is unable to leave the facility, 4 of 8 staff stated residents are able to sit outside in the sun without supervision. Prior to the fall, 3 of 8 staff stated R1 was communicative of R1’s needs to staff. S7 stated that R1 was not a risk of AWOLing. S1 and S8 stated R1 did not require constant supervision and the facility does not monitor front door at all times. S2 stated the facility’s policy is for residents to sign out when they leave the property but not when sitting outside.

Based upon the interviews conducted and information obtained during investigation. The above allegations are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC9099 (FAS) - (06/04)

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