306000752-6-10-2024-22-AS-MTEA-D64VJB-20240610162828

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000752
Report Date: 06/10/2024
Date Signed: 06/10/2024 04:29:02 PM

Document Has Been Signed on 06/10/2024 04:29 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ATRIA GOLDEN CREEK		FACILITY NUMBER:	306000752
ADMINISTRATOR:	JAMES D. CRADDOCK		FACILITY TYPE:	740
ADDRESS:	33 CREEK RD		TELEPHONE:	(949) 786-5665
CITY:	IRVINE	STATE: CA	ZIP CODE:	92604
CAPACITY:	155	CENSUS: 102	DATE:	06/10/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:21 PM
MET WITH:	Dori Redman		TIME COMPLETED:	04:45 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	Licensing Program Analyst (LPA) Michael Tea conducted a case management visit to follow up on an incident report received by Community Care Licensing (CCL) on May 24, 2024 submitted by Resident Service Director (RSD) Elaheh Mobadifar. LPA was greeted and allowed entrance into the facility by Executive Director (ED) Dori Redman. LPA explained the reason for the visit. The purpose of this visit is for a case management incident where a resident eloped from the facility on May 24, 2024 and was found by Staff 1 (S1), Memory Care Medical Assistant/Med-Tech still on facility property. LPA requested resident file and staffing schedule. LPA interviewed S1. S1 was alerted by a private caregiver (S2) of a resident in memory care, who was near by in the memory care dining room when the alarm had gone off. S1 saw that the alert was coming from the back gate with delayed egress. S1 discovered the resident standing on the parking lot by the back gate of the facility. The parking lot has no traffic and has only one car parked at the time. Resident was immediately safely brought back to her room and she immediately reported the incident right away. LPA interviewed resident (R1) to ensure she was okay. Resident did not recall the incident, she is diagnosed with dementia. R1 stated that she was okay and said that she wants to go home. She waved to S1 and told LPA that S1 is her friend who helped her get back to her room, which was her only recollection of the event. Reviewing R1's file she is unable to leave the facility unassisted. None of the staff did not see R1 leave the facility because residents are allowed to walk around the memory care. The back gate where she was found is part of the large court yard of memory care where residents can sit and walk around. LPA tested delayed egress of the back gate to see the staff response. Within less than a minute, staff came to check what was going on and to make sure everything was alright. They responded in an appropriate timely manner. Continuation of Case Management on LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ATRIA GOLDEN CREEK	FACILITY NUMBER: 306000752
	VISIT DATE: 06/10/2024

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Based on LPA observations and interviews there was adequate staffing at the time. Staff immediately responded to the alarm and followed protocol and immediately reported the incident right away to the department. Resident was still on the property of the facility and did not go off the property. Resident is safe and was monitored closely after the incident.

No deficiencies are being cited as a result of this visit.

An exit interview was conducted with Executive Director, Dori Redman and a copy of this report was provided with the LIC 811 at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

LIC809 (FAS) - (06/04)

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