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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000389
Report Date: 03/24/2023
Date Signed: 03/24/2023 02:33:18 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/09/2022 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20221209100006
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: 178DATE:
03/24/2023
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Kimberly Hagen, Executive DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility is overcharging a resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Kimberly Hagen, to deliver findings into the complaint allegation listed above.

During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility is overcharging a resident in care

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
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 3
Control Number 25-AS-20221209100006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: ATRIA EL CAMINO GARDENS
FACILITY NUMBER: 347000389
VISIT DATE: 03/24/2023
NARRATIVE
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Relevant party indicated that a resident in care was being charged more than the agreed amount listed on their admission agreement.

LPA observed resident (R8’s) admission agreement signed 10/27/2022 and invoices itemizing charges from October 2022 to March 2023. LPA observed that charges for level of care services and pre-admission fees were included in R8’s signed admission agreement. LPA observed that invoice for January 2023 showed a charge for $530 for medication services when, according to interviews with staff members S1, S2, and ED, as well as a review of R1’s Physician’s Report for RCFE LIC 602A dated 12/9/2022 (faxed to the facility on 12/13/2022), R8 was not receiving medication services. LPA observed that $530 were credited back to R8 on invoice for February 2023.

LPA observed a charge for $4012.50 for “Private Duty Personnel” for R8’s March 2023 invoice. Interview with ED indicated that service was provided due to an incident in which R8 attempted suicide on 1/1/2023. R8’s updated LIC 602A dated 1/10/2023, which was completed during hospital visit following incident that occurred on 1/1/2023, indicated R8 as not exhibiting suicidal/self-abuse behaviors and not experiencing depression. A comment on the last page of R8’s LIC 602A dated 1/10/2023 indicates that R8 had a “suicide attempt by overdose” but also states that R8 “is not acutely a suicidal or homicidal.” Interview with ED indicated that R8 did not agree to private duty personnel services and implementation of services for R8 was decided by facility. Interview with ED indicated that a meeting with R8 and the facility was attempted to address service implementation, but R8 refused to participate in meeting with facility.

R8’s admission agreement signed on 10/27/2022 states “If you become a safety risk to yourself or to others during your residency, we have the right in our sole determination to obtain, at your expense, private duty personnel to provide supervision or assistance until you move from the Community or your safety is no longer at risk.” Due to Incident that occurred on 1/1/2023, the facility began providing additional supervision for R8 to ensure their safety.

Interviews conducted with residents R1, R2, R3, R4, R5, R6, and R7, staff members S1, S2, S3, S4, S5, S6, S7, S8, S9, and ED indicated that there have been no incidents witnessed in which the facility charged a resident fees not indicated in their admission agreement.

** Report continued on 9099-C **
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 25-AS-20221209100006
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: ATRIA EL CAMINO GARDENS
FACILITY NUMBER: 347000389
VISIT DATE: 03/24/2023
NARRATIVE
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Based on interviews conducted and observations, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means 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 was conducted with Executive Director and a copy of this report was provided to the facility. The signature of the Executive Director on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3