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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000389
Report Date: 07/26/2021
Date Signed: 07/26/2021 04:26:24 PM



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
03/22/2021 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210322151401
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: 224DATE:
07/26/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alicia Rist, Executive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not shower resident
Staff did not allow resident to smoke
Staff did not supervise resident when smoking
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation and deliver findings to a complaint received on 3/22/2021. LPA met with Alicia Rist, Executive Director, and explained purpose of inspection. Prior to initiating today's inspection, 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. LPA confirmed there are currently no Covid cases at the community.

During the investigation, LPA interviewed the Administrator, Resident Services Coordianator, (1) nurse, (4) caregiver/med-tech staff and resident's representative. LPA reviewed the following documents pertaining to resident (R1) including, but not limited to, physician's report, assessments and care plans, monthly assignment report, incident reports, admission agreement and home health records.

The results of the investigation are as follows:



cont on 9099C..
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: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
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 11
Control Number 27-AS-20210322151401
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: 07/26/2021
NARRATIVE
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Resident (R1) moved to facility on/around 1/10/2021 with a physician's diagnosis of Emphysema, age related brain atrophy/mild cognitive impairment, was non-ambulatory and used a motorized power chair for ambulation. Admissions agreement was signed on 12/29/2020. Physician's report dated 11/11/2020 notes that resident had minor confusion, was independent with dressing, feeding, and medications and could transfer independently to/from bed but needed help balancing to be able to shower/bathe. Pre-appraisal dated 12/29/2020 notes that resident is a smoker, used a wheelchair but could get in and out unassisted and needed help with bathing. Resident later received a diagnosis of dementia on 2/26/2021.

Allegation: Staff did not shower resident

Complaint alleges that facility did not shower resident for 2 weeks and when resident’s representative asked about the showers the facility stated resident was refusing.

Resident’s care plan dated 1/10/2021 documents that resident needed “minimal assistance” with showers, scheduled once per week, and staff will stand by and provide assistance with preparing all bathing supplies, and assist with escorting in and out of shower/tub. Care plan was updated on 1/13/2021 and again on 1/22/2021 with no change in shower assistance noted on either assessment.

LPA reviewed an e-mail, dated 1/25/2021, from facility responding to resident’s representative about resident not being showered in 2 weeks: E-mail states that care staff reported on 1/24/2021, Sunday, that resident refused a shower, stating he already took one and that a shower would be given that day, 1/25/2021, Monday, even though resident’s scheduled showers are on Sundays. E-mail further states “Staff understand the importance of completing this task as scheduled, we reviewed again today”.

Resident Monthly assignment report for January 2021 shows that an entry was made on 1/10/2021, 1/17/2021 and on 1/24/2021 and a shower was only completed on 1/24/2021. Executive Director indicated she cannot say with certainty if resident received a shower or not on 1/10/2021 or on 1/17/2021 based on the documentation on the report. The same report shows that there are were no showers given for February 2021, and the only entry made, on 2/22/2021, notes that resident did not receive a shower due to not being available. Other documentation reviewed confirms that resident was out of the facility starting on 2/8/2021 (pm) and did not return until 3/3/2021 (pm) following a fall and recovery stay at a skilled nursing facility.
cont on 9099C(2)






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

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 11
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
03/22/2021 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210322151401

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: 224DATE:
07/26/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alicia Rist, Executive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not ensure resident was taken to Dr. appointments
Resident charged for services that were not provided
INVESTIGATION FINDINGS:
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During the investigation, LPA interviewed the Administrator, Resident Services Coordianator, (1) nurse, (4) caregiver/med-tech staff and resident's representative. LPA reviewed the following documents pertaining to resident (R1) including, but not limited to, physician's report, assessments and care plans, monthly assignment report, incident reports, admission agreement and home health records.

The results of the investigation are as follows:

Allegation: Staff did not ensure resident was taken to Dr. appointments:

Complaint alleges that resident missed (2) doctor appointments (1/19/2021 and 3/19/2021) and had a third tele-health appointment (1/25/2021) that the facility did not coordinate.

Admission Agreement states in Section 2(a)(5) under Resident Services that assistance in arranging transportation to medical and dental appointments is included in the standard service which is part of the standard rate.

cont on 9099(C)...
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: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 11
Control Number 27-AS-20210322151401
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: 07/26/2021
NARRATIVE
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On 1/19/2021, Tuesday, resident representative stated resident had an appointment for a TB test and the facility was supposed to take him. LPA reviewed e-mail documentation, dated 1/25/2021, from resident representative to Executive Director, stating, in part, that resident had a doctor’s appointment on Tuesday for a TB test and that facility was advised of resident’s doctor’s appointment.
E-mail response sent later in the day on 1/25/2021 states that the facility is not sure how the appointment was missed and that the driver is available to take resident to his next appointment.

Executive Director stated the facility has (2) bus drivers that take residents to and from doctor's appointments, and transportation requests need to be made in sufficient advance time and last-minute requests, made the same or prior day, may not be able to be accommodated. Facility uses a bus book to track appointments scheduled in advance. LPA was not able to obtain documentation from the bus book for months January and February 2021.

LPA interviewed Resident Services Coordinator (RSC) regarding virtual appointment resident was reported to have on 1/25/2021. RSC stated she recalls resident having a scheduled tele-health appointment on one day but resident was not present at the facility that day and was unsure of the appointment date. RSC stated she doesn’t recall assisting resident on any date and would have entered notes in resident’s electronic file following the appointment. Interview with facility nurse confirmed that RSC or another nurse would have handled the tele-health appointment and normally either resident’s physician and/or family member would need to notify the facility prior to the tele-health appointment and provide an email with the password. Executive Director stated that the facility had adjusted months prior, when the Covid-19 lockdown began, in facilitating virtual appointments with residents and she had not heard of any resident missing a scheduled appointment, stating the facility had purchased multiple I pads to assist residents and families.

Resident representative stated the resident had an appointment on 3/19/2021 to take a Covid test prior to moving out, and the facility indicated they did not have their bus available on that day to take resident and an outside bus would be needed. Resident representative stated the outside bus arrived but would then not take resident to the appointment.

LPA reviewed several e-mails dated 3/18/2021 and 3/19/2021 between Executive Director and resident representative regarding arranging transportation services for resident’s appointment on 3/19/2021. In summary, e-mails indicate that that the first transportation company was unable to take resident on 3/19/2021 and was requiring facility staff stay with resident since resident has Dementia.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
LIC9099 (FAS) - (06/04)
Page: 9 of 11
Control Number 27-AS-20210322151401
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: 07/26/2021
NARRATIVE
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9099C(2)..Additional e-mails explain that a second transportation company was contacted that was available on 3/19/2021 to take resident, stay with him and bring him back and that the facility could cover the cost and that resident representative approved..

LPA reviewed another subsequent email sent on 3/19/2021 (3:14 pm) from facility to resident representative explaining that the transportation service was unable to take resident to the appointment earlier in the day due to resident’s transfer ability out of the vehicle, and no facility staff would be there to help assist. Executive Director stated and e-mail documents that the facility offered to test resident for Covid at the facility the following week; however, resident’s representative worked it out with the new facility to come and test resident at the facility. Resident moved out on 3/24/2021.

Based on information obtained, 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.


Allegation: Resident charged for services that were not provided

Allegation is resident was moved from Level 1 to level 2 on 1/13/2021 and the resident representative was emailed a new assessment that wasn’t agreed to. Also, resident was at the hospital on 2/7/2021 and then rehabilitation on 2/12/2021 and did not return to the facility until 3/2/2021 and was charged for services while out of the facility.

LPA reviewed an email dated 1/13/2021 from Executive Director to resident representative which included the revised care plan after discussing with RSD,and requested a signature from resident representative and to advise of any questions or concerns.

Executive Director stated that resident representative did not sign the assessment and so put the resident back on Level 1 care and charged separately for laundry services. LPA reviewed email sent on 1/25/2021 from Executive Director to resident representative stating the care plan was reviewed again with RSD and services for housekeeping, bathing and escorts will fall within Level 1 (199 points) and laundry will be charged as an ancillary charge. cont on 9099C(3)...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
LIC9099 (FAS) - (06/04)
Page: 10 of 11
Control Number 27-AS-20210322151401
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: 07/26/2021
NARRATIVE
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Resident representative stated he signed care plan dated 3/3/2021 where resident was placed at a Level 4 upon returning from skilled nursing.

Resident representative stated to LPA that any charges that were inadvertently billed to him were corrected once the long-term care provider was brought into the discussion and he is not owed any funds.

Based on information obtained, 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.

There are no deficiencies being cited for these (2) allegations found to be Unsubstantiated.

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

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
LIC9099 (FAS) - (06/04)
Page: 11 of 11
Control Number 27-AS-20210322151401
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: 07/26/2021
NARRATIVE
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9099C(2)..Interview with one staff indicated that resident did refuse showers when he was "very new", adding that staff tried a "change in face and he still refused'. The same staff stated that if the resident wants a sponge bath staff will give it, stating “Resident (R1) was cold all of the time".

A second staff also stated that resident did refuse showers in the beginning, and “ was reluctant when I told him it was time for his shower". Staff stated she was instructed by the Med-Tech to ask resident to sign a refusal form when refusing his shower. Staff stated the next time she told resident it was his shower time, he did allow her to give him a sponge bath once she explained that it was a sponge bath only, stating "He only refused the full shower -he was just uncomfortable with people bathing him". A third staff stated “(R1) was scheduled for a shower one time per week- we had been trying for a couple of weeks and he wouldn't take a shower. Finally staff (S1) was able to get him to shower and it was at an odd time of day.”

Additional staff stated she gave resident a shower “only 1 time" and when resident moved in, he said he didn't want any help with showers and could shower himself. Staff stated she told resident that his son wanted him to have a shower and he said "okay" and explained that when she assisted resident, he "couldn't put his foot on the shower- it was difficult for him , transferring- I think he was scared to step as he thinks he will fall". Resident Monthly assignment report for March 2021 shows this staff gave resident a shower on 3/15/2021 and on 3/22/2021. Notes entered on 3/1/2021 and 3/29/2021 correctly reflect that a shower was not given since resident was not available due to being out of the facility.

Executive Director stated in an interview that if a resident refuses a shower, staff will try a "change of face and contact resident representative and continue to try showers with different staff on different days and times. Additionally, staff will typically document when a service is refused. Resident likely received a sponge bath based on interviews; however, sponge baths are not typically documented.

Based on information obtained, 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.

cont on 9099C(3)...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 11
Control Number 27-AS-20210322151401
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: 07/26/2021
NARRATIVE
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9099(C)(3)...Allegation: Staff did not allow resident to smoke: Complaint alleges that resident was being combative on/around 3/6/2021, and staff did not allow resident to smoke.

LPA reviewed emails dated 3/7/2021 between resident’s representative and Resident Services Director (RSD) discussing how resident was not able to go outside and smoke on 3/6/2021 around 10:00 pm, as requested. Email response from RSD states “I spoke with the staff and clarified to them that your dad has the right to smoke. I assure you it won't happen again.”

Interview with (3) staff indicated that resident was denied a smoke break once on their shift. One staff stated that she told resident he couldn't go outside and smoke- “because it was too late at night", around 9-10- pm. Staff stated that resident was "insisting to go out" and smoke and she didn't tell resident "no" but he accepted after a while and this was the only time on her shift this happened. Staff stated this particular night it was a little rainy also.

Two staff stated resident was not given a smoke break due to resident not having a lighter available. Staff explained that resident’s cigarettes and lighter were kept in the medication room previously when he returned from skilled nursing and staff "couldn't find it" with another staff stating "we couldn't find a lighter during the shift- we finally found one- a caregiver had one". Staff explained that they were told they took all of his lighters " because he had smoked a couple of times in his room” and that resident kept his cigarettes. Email dated 3/8/2021 (12:36 pm) from Executive Director to resident representative advised that resident needs a new lighter and RSD went to purchase one for resident in the interim.

LPA reviewed e-mails dated 3/7/2021 between resident representative and facility stating that he was contacted around 10:00 pm on 3/6/2021 by his father after a staff told him he couldn’t smoke. E-mail response sent by facility later on 3/7/2021 states that facility staff were made aware that resident has the right to smoke and that a similar incident won’t happen again.

Based on information obtained, 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.
cont on 9099C(4)..
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 11
Control Number 27-AS-20210322151401
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: 07/26/2021
NARRATIVE
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9099C(4)...Allegation: Staff did not supervise resident when smoking
Complaint alleges that resident was left in the rain in the designated smoking section without supervision.

Resident care plan dated 1/10/2021 indicates that resident does not require escorting services but resident is a smoker and to encourage resident to use the smoking area.

Resident care plans dated 1/13/2021 and 1/22/2021 note that resident requires escorts and assistance to attend meals and/or activities, 3 times/day. It is also noted that resident smokes and to escort resident to the smoking area and stay with resident and allow resident 10 minutes to smoke.

LPA reviewed facility internal incident report from 1/20/2021 at approximately 4:30 pm. Report states that resident was found on the ground at the smoking area and staff was made aware when resident pushed his pendant for assistance. Resident did not report any pain or injury and refused medical attention. Staff who reported the incident to the facility stated in an interview that she escorted resident to the outside smoking area, resident then sat on the bench and she stayed with him for a while until she received another call. Staff stated that "(R1) would try to transfer himself and I would tell him to press the button if you need help".

LPA reviewed another incident report from 2/8/2021, at approximately 5:50 pm, which notes that resident was found on the floor near the smoking area exit. The same staff stated that resident fell inside and the receptionist saw resident slip from his wheelchair. Resident was sent out for further evaluation following this fall and did not return until 3/3/2021. Another staff stated in an interview that resident must smoke at the bench and there is a slight slope getting to the bench.

Based on information obtained, 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 Code of Regulations, Title 22, Division 6, Chapter 8, the following (3) deficiencies are cited on 9099D pages.

Exit interview and copy of report and appeal rights printed and provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 11
Control Number 27-AS-20210322151401
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: 07/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2021
Section Cited
CCR
87464(d)
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87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.
This requirement is not met as evidenced by:
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Licensee/Administrator agree to conduct in-service training with all care staff on how to handle residents who refuse scheduled care.

Facility to fax copy of agenda/attendees to CCLD by 8/9/2021.
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Based on interviews and documentation reviewed, the Licensee did not ensure that resident (R1) was assisted with weekly showers, per care plan dated 1/10/2021, and given a shower on 1/10/2021 and on 1/17/2021, which posed a potential health and safety risk to resident in care.
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Type B
08/09/2021
Section Cited
CCR
87468.2(a)6)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility.
This requirement is not met as evidenced by:
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Licensee/Administrator agree to conduct in-service training with all care staff on personal rights.

Facility to fax copy of agenda/attendees to CCLD by 8/9/2021.
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Based on interviews and record review, the Licensee did not ensure that resident (R1) was allowed a smoke break on 3/6/2021 at approximately 10:00 pm when requested, which posed a potential personal rights violation to resident 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: 07/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 11
Control Number 27-AS-20210322151401
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: 07/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2021
Section Cited
CCR
87464(d)
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87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.
This requirement is not met as evidenced by:
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7
Licensee/Administrator agree to conduct in-service for all care staff on followng care plan instructions.

Facility to fax copy of agenda/attendees to CCLD by 8/9/2021.
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9
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14
Based on interviews and record review, the Licensee did not ensure that resident (R1) received supervision from staff, per resident's care plan dated 1/13/2021, during a smoke break on 1/20/2021, which posed a potential health and safety risk to resident in care. Resident fell on the ground during a smoike break and used his pendant to call staff for assistance.
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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: 07/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 11