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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000389
Report Date: 05/17/2022
Date Signed: 05/17/2022 05:47:24 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2021 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20211020154446
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: 172DATE:
05/17/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Kimberly Hagen, Administrator TIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Resident left facility and staff didn't know
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on 10/20/2021. LPA met with Kimberly Hagen, Administrator. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask.

During the investigation, the Department interviewed Senior Executive Director (SED), Kimberly Hagen, prior Assistant Executive Director (AED), Barbara Fleck, Business Office Director (BOD), Deborah Ahrens, the Ombudsman and (1) family member of resident (R1). The Department reviewed documents pertaining to Resident (R1) including, but not limited to: resident charting notes, care plans, physician’s report, Ombudsman report, Unusual Incident/Injury Report (LIC624), Resident Agreement, video surveillance, text messages between facility and resident's family member and local law enforcement reports. The results of the investigation are as follows:

report cont on 9099C(1)..
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
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 8
Control Number 25-AS-20211020154446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 EL CAMINO GARDENS
FACILITY NUMBER: 347000389
VISIT DATE: 05/17/2022
NARRATIVE
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9099C(1).. Allegation: Resident left facility and staff didn't know.

Resident (R1) moved to the facility in April 2021 with a diagnosis of Mild Cognitive Impairment (MCI), occasional confusion, history of alcohol abuse, uses a walker/cane at times due to leg weakness, and Resident's physician's report dated, 4/16/2021, also states that resident is to avoid alcohol due to medications being taken. Resident's Functional Needs assessment, or care plan, was updated on 8/30/2021 as part of a quarterly update, and again on 9/24/2021 for a "Change in Condition". Both assessments note that resident is non-ambulatory and is not able to leave the community unassisted. The assessment conducted on 9/24/2021 notes the only change is that resident has a diagnosis of Vascular Dementia, and now requires status checks, 10 times daily.

Executive Directors stated on 10/27/2021 that resident went missing on October 16, 2021 and returned on their own on October 17, 2021, around 10:04 am. LIC624 says “resident signed out of the community with a friend, at approximately 1:15 pm on 10/16/2021”. Local law enforcement report for the incident says that "(resident) temporarily checked himself out for the day.... then left the facility with an unknown woman... and (resident's) family member was later contacted by the assisted living facility when staff was unable to locate (resident)..." On 10/16/2021 at 9:35 pm, law enforcement contacted Business Office Director (BOD) by telephone who stated that between 12:30 pm- 2:00 pm, on 10/16/2021, an unknown woman, carrying a grocery bag, attempted to visit resident but did not have proof of a Covid-19 vaccination. LIC624 states "resident and friend informed the community they would be leaving together".

One video surveillance provided to the Department shows the visitor walking into the facility, on 10/16/2021 at 12:58 pm, with a bag, was given a mask to wear by facility staff, and then exited the facility, waiting outside near the entrance. A second video surveillance provided by the facility shows resident (R1) to be exiting the facility on 10/16/021 at 1:05 pm, walking from the lobby reception area outside the front entrance.

The law enforcement report notes that BOD stated that residents are allowed to check themselves out of the facility if accompanied by a coherent adult, living outside of the community, and residents are not given a curfew but are instructed to notify the facility if they will be away longer than 24 hours. Additionally, law enforcement confirmed that the facility check out logs do not document or identify who residents leave with, but only note the resident's name and time resident leaves/returns. The report indicates that facility staff stated that resident (R1) has been known to temporarily check out of the facility for several hours, but has always returned. Resident's family member stated she was not aware that resident ever left.
cont on 9099C(2)..
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 25-AS-20211020154446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 EL CAMINO GARDENS
FACILITY NUMBER: 347000389
VISIT DATE: 05/17/2022
NARRATIVE
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9099C(2)..Resident’s family member stated in an interview to LPA that a facility Med-Tech (S1) called her on 10/16/2021, around 7:30 pm, and left a message that she was looking for the resident to administer his evening medications. Resident’s family member stated that when she returned the call, she was instructed to speak to the Business Office Director (BOD) who advised her that resident “had signed himself out earlier in the day”. Facility provided a sign out sheet, dated 10/16/2021, showing that BOD signed resident out at 1:00 pm and wrote the note "Care staff notified" in the column, "Time In" and additional notes "advised care staff of no return" with no time reference.

Resident's notes were reviewed that were entered by several staff members regarding the incident on 10/16/2021. On 10/18/2021 (7:49 pm), staff (S3) documented that resident missed 5 pm and 8/9 pm medications scheduled on 10/16/2021 and that resident left the facility without letting facility staff know. There were no resident notes entered on 10/17/2021. On 10/18/2021 (8:23 pm), SED entered notes that multiple texts and messages had been left for resident’s family members (2) and on 10/18/2021 a message was left for resident’s Power of Attorney that resident purchased alcohol on a grocery outing. On 10/18/2021 (10:58 pm), staff (S2) entered notes that facility staff met with resident to discuss the recent incident and how it poses a safety hazard to resident and to the community. These same notes indicate that resident’s friend signed resident out for a visit off-site before resident left with the visitor and that resident returned to the community in possession of a lot of alcohol. Review of the Ombudsman’s report notes that on 10/21/2021, the Ombudsman and Assistant Executive Director met and discussed the “check-out/check-in system used” at the facility and AED indicated that they “now have a formal system” in place since resident left the facility with an unknown woman and was gone for an extended period of time.

LPA discussed with SED and BOD who stated there is not a specific letter on file from resident's doctor stating that resident can only leave with a family member or with the facility on a group outing. BOD stated that it was her understanding that resident was able to leave the facility if accompanied by another individual/escort.

Based on information obtained during the investigation, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is cited on the 9099D page.

Exit interview. Copy of report provided to Executive Director.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 25-AS-20211020154446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 EL CAMINO GARDENS
FACILITY NUMBER: 347000389
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2022
Section Cited
CCR
87705(c)(4)
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87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:
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Administrator updated sign-out logs to include additional contact information for resident and visitor.
Administrator agrees to review all Assisted Living resident files with a dementia diagnosis and update the list kept at reception regarding residents who can leave unassisted
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Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) did not leave the facility, on 10/16/2021, accompanied in a group, as directed by resident's physician, which posed an immediate health and safety risk to residents in care.
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Training plan discussed during today's exit interview- training to be conducted by 6/3/2022.

Agenda/attendees to be provided to the Department by 6/30/2022.
CCR
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There is no second citation issued on this page.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2021 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20211020154446

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: 172DATE:
05/17/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Kimberly Hagen, Administrator TIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Resident rates increased without justification
Staff didn't notify family when resident was not in facility
Staff didn't call emergency services when resident left per their agreement.
INVESTIGATION FINDINGS:
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During the investigation, the Department interviewed Senior Executive Director (SED), Kimberly Hagen, prior Assistant Executive Director (AED), Barbara Fleck, the Ombudsman and (1) family member of resident (R1). In addition, the Department reviewed documents including, but not limited to, text messages between facility and resident's family member, LIC624, updated resident care assessment, dated 9/24/2021, and other documentation.

The results of the investigation are as follows:

Interview with Executive Directors (EDs) on 10/27/2021, confirmed that resident R1 had a change in diagnosis to Vascular Dementia, on 8/13/2021, and needed to be checked on regularly based on resident's behaviors, pursuant to the facility’s in-house policy.

cont on 9099C(1)...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 25-AS-20211020154446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 EL CAMINO GARDENS
FACILITY NUMBER: 347000389
VISIT DATE: 05/17/2022
NARRATIVE
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9099C(1).. LPA reviewed the Resident's Functional Needs assessment, or care plan, was updated on 8/30/2021 as part of a quarterly update, and again on 9/24/2021 for a "Change in Condition". Both assessments note that resident is non-ambulatory and is not able to leave the community unassisted. The assessment conducted on 9/24/2021 notes the only changes is that resident has a diagnosis of Vascular Dementia, and now requires status checks, 10 times daily, and shows all care needs to be (210 points) related to status checks.

EDs stated that R1’s rate had increased due to the change in diagnosis and that R1’s family was notified of the rate change. In the same interview, AED stated that the rate increases when a resident has Dementia because staff have to increase monitoring, to every 2 hours, and that it's the facility's policy that anyone in Assisted Living with Dementia is required to be checked on regularly, due to behaviors. Both SED and AED stated that resident's rate had increased due to the change in diagnosis and that resident's family was notified of the rate change. LPA was provided with a copy of a "Change in Assisted Living Services" letter, dated 9/27/2021, sent to resident (R1) advising of a change in supportive services. In the same notification, resident is listed as his own "Responsible Person". BOD stated that resident informed her of his change in diagnosis to Vascular Dementia, a few weeks following his appointment on 8/13/2021, and the medical documentation was forwarded to the AED or care department, who then completed an updated assessment on 9/24/2021.

Ombudsman report states that the updated Functional Needs Assessment was discussed with AED on 10/21/2021, who stated that the reassessment is done annually on all residents with a diagnosis of Dementia living in all facilities.

Family member stated they did not believe status checks were necessary every two hours as resident’s condition had not changed since April 2021 when resident moved in and resident was previously taking medications prescribed for a Dementia diagnosis when resident lived out of state. Physician’s Report, dated 4/16/2021, notes that resident has a diagnosis of Mild Cognitive Impairment (MCI) and cannot leave the facility unattended but can attend shuttle shopping trips with a group at the facility.

Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED-meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

cont on 9099C2)...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 25-AS-20211020154446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 EL CAMINO GARDENS
FACILITY NUMBER: 347000389
VISIT DATE: 05/17/2022
NARRATIVE
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Allegation: Staff didn't notify family when resident was not in facility.

LIC624 for incident states “resident signed out of the community with a friend, at approximately 1:15 pm on 10/16/2021” and .... “When resident did not return as expected, community called family. Community and family were unable to reach resident or friend via phone. Law enforcement was called. Resident failed to return for his evening and following morning doses of medications."

Resident’s family member stated she was first informed about resident leaving the facility when a facility Med-Tech called her on 10/16/2021, around 7:30 pm, and left a message telling her that she was looking for resident to administer his evening medications.

SED and AED stated on 10/27/2021 in a Department interview that resident's son is the emergency contact, and one of resident's daughter will step in when resident's son is unavailable. Text messages provided to the Department document a discussion with resident's son and SED on 10/17/2021 at 9:49 am regarding who the female visitor was, as shown in the video surveillance.

BOD stated on 5/17/2022 that the facility front desk closes at 7:30 pm and around 6:30-7:00 pm, while staff is preparing to close, they will check the sign-out log and see if there are any residents who haven't returned yet. BOD stated that it was "not unusual for (R1) to come back late" after leaving and resident's family was contacted shortly after resident had not returned.

Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED-meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 25-AS-20211020154446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 EL CAMINO GARDENS
FACILITY NUMBER: 347000389
VISIT DATE: 05/17/2022
NARRATIVE
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Allegation: Staff didn't call emergency services when resident left per their agreement.

LIC624 submitted for incident on 10/16/2021 reads, in part, “When resident did not return as expected, community called family. Community and family were unable to reach resident or friend via phone. Law enforcement was called...." BOD stated she contacted law enforcement when resident didn't return around 6:30-7:30 pm and spoke with law enforcement on 10/16/2021, again at 2 subsequent times, to provide additional information. BOD stated she is not clear if she called 9-1-1- or non-emergency line. SED provided police number to resident's other family member, on 10/17/2021, who requested it.

The family stated they would follow up and file a "Missing Person's" report.

SED stated in a text message, on 5/5/2022, that resident's daughter made the police report after the facility notified her that resident had left the facility. Resident's family member stated to LPA, on 3/11/2022, that she called law enforcement immediately after being informed that resident was not found in the facility. Law enforcement report, dated 10/16/2021, identifies the reporting party (RP) as resident's family member.

Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED-meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview. Copy of report provided to Executive Director.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8