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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200326
Report Date: 06/05/2025
Date Signed: 06/05/2025 01:32:09 PM

Substantiated


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
01/23/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20250123123225
FACILITY NAME:ATRIA PARK OF LAFAYETTEFACILITY NUMBER:
079200326
ADMINISTRATOR:ANTHONY, KAWANAFACILITY TYPE:
740
ADDRESS:1545 PLEASANT HILL RDTELEPHONE:
(925) 932-9910
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:130CENSUS: DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Kawana Anthony/National Operations Specialist-Interim Excutive DirectorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not respond to resident's requests for assistance in a timely manner
INVESTIGATION FINDINGS:
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At 12:05 pm on this day, June 5, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with National Operations Specialist/Interim Executive Director Kawana Anthony, and informed the reason for visit.

During the course of investigation, the Department obtained copies residents roster and staff schedule. Copies of including but not limited to the following residents’ documents were obtained: Resident Face Sheets; LIC601 Identification and Emergency Contact Information; Admission Agreements; LIC602A Physician's Reports; Pre-placement Appraisals; Functional Needs Service Plans; Unusual Incident Reports; Notification of Incident or Change of Condition; call button logs/records for November 17, 2024 to November 23, 2024.The following were interviewed: resident’s family member (FM1) on 2/26/25; staff (S1, S4) on 3/12/25; 3 residents on 4/10/25

......continued on 9099C (page 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 15-AS-20250123123225
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: 06/05/2025
NARRATIVE
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Page 2

It was alleged that resident pushed the call button more than once and was not responded timely.

FM1 stated that on 11/18/24, around 8 pm, R1 needed help with getting to the bathroom. R1 pushed his call button for assistance four times, and nobody responded, so R1 got up on his own and fell.

The Department interviewed former Resident Services Director (S1) who stated that call button calls should be answered within 10 minutes. One of the 3 residents interviewed stated that staff responded to her call in 10, 15 minutes and at times this resident waited for 20 minutes. The other resident stated that staff know who is calling and may have a different response to each resident.

Review of call button call records confirmed R1 pressed the call button 4 times on 11/18/24 and was responded only after 14 minutes. Documents also showed several residents pressed their call buttons more than once to as many as 7 times and took the staff to respond longer than 10 minutes to 30 minutes.

Based on interviews and records review, the preponderance of evidence standard has been met, therefore, the allegation is substantiated.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Kawana Anthony,

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Citations on this Visit Report are Under Appeal!

Control Number 15-AS-20250123123225
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
06/06/2025
Section Cited
HSC
1569.269(a)(6)
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§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers,
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Interim Executive Director to in-service the staff and copy of training topic(s) with attendees signatures to be submitted by 6/06/25.
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qualifications, and competency to meet their needs.
-This requirement is not met as evidenced by:
-Based on records review and interviews, the licensee did not comply with the section when staff did not respond to residents' call timely which posed an immediate safety and/or personal right risks to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
01/23/2025 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20250123123225

FACILITY NAME:ATRIA PARK OF LAFAYETTEFACILITY NUMBER:
079200326
ADMINISTRATOR:ANTHONY, KAWANAFACILITY TYPE:
740
ADDRESS:1545 PLEASANT HILL RDTELEPHONE:
(925) 932-9910
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:130CENSUS: DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Kawana Anthony/National Operations Specialist-Interim Excutive DirectorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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-Staff neglect led to the death of resident.

-Staff did not seek medical attention for resident in a timely manner
INVESTIGATION FINDINGS:
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At 12:05 pm on this day, June 5, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with National Operations Specialist/Interim Executive Director Kawana Anthony, and informed the reason for visit.

During the course of investigation, the Department obtained copies resident roster and staff schedule. Copies of including but not limited to the following residents’ documents were obtained and reviewed: Resident Face Sheets; LIC601 Identification and Emergency Contact Information; Admission Agreements; LIC602A Physician's Reports; Pre-placement Appraisals; Functional Needs Service Plans; Unusual Incident Reports; Notification of Incident or Change of Condition; medical records; Emergency Medical Services (EMS) record; death certificate. The following were interviewed: resident’s family member (FM1) on 2/26/25; staff (S1, S2, S3, S4, S5, S6) on 3/12/25; 3 residents on 4/10/25

.....continued on 9099C (page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20250123123225
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: 06/05/2025
NARRATIVE
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Page 2

Allegation: Staff neglect led to the death of resident (R1).
It was reported that resident (R1) had fallen prior to moving to the facility and that facility staff were aware that R1 was a fall risk. Reporting party (RP) also indicated that R1 fell twice at the facility and on the first fall, R1 was not sent out to the hospital. On the 2nd fall incident on 11/18/24, R1 needed help at around 8:00 pm and was not responded timely, R1 got up by himself, fell, broke the right leg, and sustained injuries to the back and hip. It was further reported that at some point, staff found R1 on the floor, picked up and put R1 back to bed. RP further indicated that R1 was sent to the hospital the following day and diagnosed with aspiration pneumonia and injury. R1 was moved to another facility where R1 passed away on 1/04/25 due to injuries and trauma from fall and pneumonia.

FM1 stated that R1 fell at the facility on 10/2024. R1 fell again on 11/2024 resulting to R1 sustaining serious injuries that contributed to R1’s death. FM1 further stated that on 10/2024, R1 was dropped by S2 in the bathroom and put R1 back to bed. S2 denied the allegation and stated he was not assigned to R1 and only escorted R1 back to his room one time.

FM1 stated that R1 was trying to use the bathroom and fell going to the bathroom on 11/2024. R1 sustained injuries to the right fibula, hip and back. R1 was assisted by S4 back to bed before S4 left at the end of S4’s shift. S4 stated he found R1 near R1’s walker on the night of the incident and that he could tell R1 was physically hurt as R1 kept saying “head hurt”. S4 further stated helping R1 to R1’s wheelchair and went to get the facility nurse, S5, who called 9-11. S5 confirmed that R1 fell on 11/2024 and that S4 called and informed S5. S5 stated she called R1’s wife, FM2, and FM2 later agreed to send R1 out to the hospital due to R1 was in pain.

S3 was not assigned to R1. S6 stated she was given instruction by S1 to investigate the fall incident that was reported by R1’s family. S6 further stated that R1 was not able to provide information about the fall incident that happened on 10/2024 and that R1 was not in pain. S1 confirmed that she instructed S6 to investigate because she wanted to complete an incident report. S1 stated that S2 denied picking up and putting R1 back to bed when R1 fell on 10/2024. S1 also stated that R1 fell again on 11/2024 and that 9-11 was called.
.......continued on 9099C (page 3)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20250123123225
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: 06/05/2025
NARRATIVE
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Page 3

Review of records showed R1 fell the first time on 10/27/24, no injuries sustained and R1 refused transport to the emergency. R1 fell the second time on 11/18/24, 9-11 called and R1 was sent out and diagnosed with a closed displaced fracture of lateral malleolus of right fibula and no other injuries. Death certificate indicated R1 passed away on 1/04/25. Cause of death was due to aspiration pneumonia and Parkinson’s disease and no other significant conditions contributing to death.

Based on records review and interviews, there is not a preponderance of evidence standard to prove that violations occurred, therefore the allegation is unsubstantiated.

Allegation: Staff did not seek medical attention for resident in a timely manner.
It was reported that on 11/18/24, R1 needed help at around 8:00 pm and was not responded timely, R1 got up by himself, fell, broke the right leg, and sustained injuries to the back and hip. It was further reported that at some point, staff found R1 on the floor, picked up and put R1 back to bed. RP further indicated that R1 was only sent to the hospital the following day.

Review of Emergency Medical Services (EMS) records indicated that there were two visits on 11/18/2024 to the facility for R1. The first EMS response and visit occurred at about 2210 hours and the second at about 2313 hours. During the first visit, Emergency Medical Technicians (EMTs) contacted R1’s wife, FM2, and informed FM2 about what happened to R1. FM2 and R1’s daughter, FM1, decided there was no need for R1 to go to the hospital. The EMTs left at about 2305 hours. The second visit at about 2313 hours resulted in R1 being transported to the hospital due to complaints of pain in his leg and back. The Department was not able to interview R1 due to R1 had passed away prior to the Department receiving the complaint. Therefore, the allegation is unsubstantiated.

Based on records review and interviews, and the Department unable to interview R1, the two allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that violations occurred.

No deficiency cited. Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6