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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005428
Report Date: 07/21/2021
Date Signed: 07/21/2021 11:53:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ATRIA ROCKLINFACILITY NUMBER:
317005428
ADMINISTRATOR:DANA STANSELFACILITY TYPE:
740
ADDRESS:3201 SANTA FE WAYTELEPHONE:
(916) 435-8800
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:105CENSUS: 80DATE:
07/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Dana Stansel, Executive DirectorTIME COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Wolter arrived at the facility unannounced on 07/21/2021 to conduct a case management visit regarding an incident report Community Care Licensing (CCL) received on 07/19/2021, LPA met with Executive Director (ED) Dana Stansel and explained the purpose of the visit.

Prior to initiating the case management, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by facility staff upon entry.

Incident report received on 07/19/2021 was in regards to an incident that occurred on 07/15/2021, resident (R1) was inadvertently given the wrong medications. Med-tech noticed the mistake immediately and the proper parties were notified, R1 was transported to the hospital and no adverse reactions were suffered.

LPA and ED discussed the incident in further detail, R1 was mistakenly handed the wrong residents medications after the med-tech had poured them and addressed another residents behaviors in the memory care unit. The med-tech was issued a final written warning, provided with additional training, and shadowed on the next shift to ensure no errors were made.

A deficiency is being cited as a result of today's visit and is on the attached LIC 809-D.

Exit interview conducted, appeal rights provided, and copy of report left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ATRIA ROCKLIN
FACILITY NUMBER: 317005428
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2021
Section Cited

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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed.
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This requirement was not met as evidenced by: interview and documentation review. The licensee failed to comply with the regulation referenced above. R1 received medications which did not belong to them. This poses an immediate health, safety, and/or personal rights risk to residents 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.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2021
LIC809 (FAS) - (06/04)
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