347000389-5-4-2023-25-AS-KHOS-CRLV72-20230507161025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000389
Report Date: 05/04/2023
Date Signed: 05/04/2023 11:02:17 AM

Unfounded

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
02/07/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 25-AS-20230207101842

FACILITY NAME:	ATRIA EL CAMINO GARDENS		FACILITY NUMBER:	347000389
ADMINISTRATOR:	KIMBERLY HAGEN		FACILITY TYPE:	740
ADDRESS:	2426 GARFIELD AVE		TELEPHONE:	(916) 488-5722
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	325	CENSUS: 188	DATE:	05/04/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kim Hagen		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Illegal eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the finding of the allegation cited above. LPA met with Executive Director, Kim Hagen, and explained the purpose of the visit.

During this investigation, LPA conducted records review and extensive interviews. LPA found the facility to be compliance with Title 22, 87224 Eviction Procedures. Based on interviews conducted, the preponderance of evidence standards have not been met. Based on information obtained during the investigation, LPA finds the allegation to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Please continue on LIC 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20230207101842

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: 05/04/2023

NARRATIVE

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Continued from LIC 9099...

Allegation Staff handled resident in a rough manner.
The Department conducted records review interviews to investigate this allegation. During interview conducted on 02/08/2023, LPA was informed that R1 had a change of health condition and has been violating House Rules as R1 continued to be disrespectful to facility staff. During records review conducted, LPA observed the 30 day eviction to list the occurrence of when R1 violated the House Rules, effective date and referral services for alternative housing. Additionally during records review, LPA observed R1's LIC 624 Unusual Incident/Injury Report to stated on 01/20/2023 and 01/21/2023, R1 was observed to be yelling and disrespectful to others. During an interview conducted on 02/07/2023 with R1, R1 admitted to telling facility staff to "fuck off" and "go to hell". Therefore, the allegation is UNFOUNDED.

Exit interview was conducted with Executive Director and a copy of this report and appeal rights was provided to Executive Director. The signature of the Executive Director on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

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