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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000389
Report Date: 08/24/2022
Date Signed: 08/24/2022 12:35:48 PM


Document Has Been Signed on 08/24/2022 12:35 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:ATRIA EL CAMINO GARDENSFACILITY NUMBER:
347000389
ADMINISTRATOR:KIMBERLY HAGENFACILITY TYPE:
740
ADDRESS:2426 GARFIELD AVETELEPHONE:
(916) 488-5722
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:325CENSUS: 169DATE:
08/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kimberly Hagen, AdministratorTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced at the facility to deliver complaint findings and also issue a citation for a deficiency discovered during the course of a recent complaint investigation. LPA met with Kimberly Hagen, Administrator, and explained purpose of inspection.

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 and confirmed there are currently multiple positive Covid cases at the community. 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: surgical mask.

During the investigation of complaint #25-AS-20220426122233, the Department reviewed documentation entitled "Secured Environment Addendum" for resident (R1) and observed it to be signed by resident's Power of Attorney on 2/25/2022. LPA discussed the document with facility Administrator, Memory Care Director and POA during a phone conference on 4/29/22 and that it does not include resident's signature. Resident's POA stated that resident clearly knew she was moving into a facility with a secured environment and was rejected for Assisted Living.

The facility was previously cited on 2/23/2018, for the same deficiency, under Health and Safety Code §1569.698(f) which reads: Any person who is not a conservatee and is entering a locked or secured perimeter facility pursuant to this section shall sign a statement of voluntary entry. The facility shall retain the original statement and shall send a copy of the statement to the department.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is cited on the 809-D page.

Exit interview. Copy of report and appeal rights provided to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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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Document Has Been Signed on 08/24/2022 12:35 PM - It Cannot Be Edited

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 EL CAMINO GARDENS
FACILITY NUMBER: 347000389

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2022
Section Cited

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§1569.698 Building standards; adoption; locked and secured perimeters in residential care facilities; persons with dementia (f) Any person who is not a conservatee and is entering a locked or secured perimeter facility pursuant to this section shall sign a statement of voluntary entry. The facility shall retain the original statement and shall send a copy of the statement to the department. This requirement is not met as evidenced by:
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Based on documentation reviewed, the Licensee did not ensure that resident (R1) signed the "Secured Environment Addendum" dated 2/25/22. The document was signed by resident's POA instead which posed a potential personal rights violation 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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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