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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000389
Report Date: 11/04/2021
Date Signed: 11/04/2021 12:41:50 PM

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 EL CAMINO GARDENSFACILITY NUMBER:
347000389
ADMINISTRATOR:RIST, ALICIAFACILITY TYPE:
740
ADDRESS:2426 GARFIELD AVETELEPHONE:
(916) 488-5722
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:325CENSUS: 201DATE:
11/04/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Kimberly Hagen, Senior Executive DirectorTIME COMPLETED:
12:55 PM
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Licensing Program Analysts (LPAs) Angela Hood and Michael Hood arrived at the facility today to conduct a case management visit regarding an incident report received by CCLD on 10/22/21. The facility currently does not have any COVID positive cases. Staff wore masks in the facility and LPAs wore N95 masks. Additionally, LPAs were screened upon entry at the facility.

On 10/22/21, CCLD received an incident report indicating that on 10/16/21 resident (R1) signed out of the community and left with a friend intending on returning to the facility the same day. R1's Physician's Report LIC602A indicates that R1 is unable to leave the facility unassisted. R1 does not have a conservator. The incident report indicates that R1 did not return the evening of 10/16/21. The facility contacted R1's family and the family contacted law enforcement. Law enforcement arrived at the facility on 10/16/21 and spoke with the Senior Business Community Director regarding R1. R1 returned to the facility the following day, 10/17/21, and the facility reported there were no adverse reactions to R1 missing doses of medication while away. Facility contacted family, law enforcement, and physician to report R1's return to the community. Senior Executive Director, Assistant Executive Director, and staff (S1) spoke with R1 regarding the house rules which state to "notify the Front Desk if you are planning to be away overnight and inform us of your expected date of return, so we know when to expect you. In the event of an emergency, please also provide us with a telephone number where you can be reached while you are away". Moving forward, the facility will obtain a contact phone number for residents in all scenarios where residents leave with an escort/visitor.

No deficiencies are being cited during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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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