347000389-5-4-2023-59-AS-KHOS-CRLVBP-20230507161751

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000389
Report Date: 05/04/2023
Date Signed: 05/04/2023 11:20:20 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
03/07/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20230307161915

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:	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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Facility is interfering with residents packages/mail.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the finding for the allegation listed above. LPA met with Executive Director, Kim Hagen, and explained the purpose of the visit. LPA ensured hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

During the investigation, LPA conducted interviews and records review for the allegation cited above.

The results of the investigation are as follows:

Please continue report 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)

Page: 1 of 4

Control Number 59-AS-20230307161915

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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LIC 9099-C...

Allegation: Facility is interfering with residents packages/mail.
The Department conducted records review and interviews to investigate this allegation. During interview conducted on 03/17/2023 with ED indicated that R1 has signed a Mailed Medication Waiver and Authorization, which authorized facility to "open such packages and store any such medication on my [resident's] behalf". ED informed LPA that in the packages retrieved obtained vitamin supplements. Record review indicated R1 did sign the waiver on 10/27/2022. Additionally on 3/17/2023, LPA interviewed R1 who confirmed to LPA he had ordered vitamins on Amazon although he was informed by facility staff that all supplements need a doctor's order. Interview indicated R1 was unaware he had signed the waiver as R1 implied the Admission Agreement packet was over 100 pages. Therefore, the allegation is UNFOUNDED.

During this investigation, LPA conducted records review and extensive interviews. LPA found the facility to be compliance with Title 22. 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.

Exit interview conducted and a copy of the report and appeal right was provided.

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)

Page: 2 of 4

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
03/07/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20230307161915

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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Facility financially abused resident.

INVESTIGATION FINDINGS:

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Unsubstantiated

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)

Page: 3 of 4

Control Number 59-AS-20230307161915

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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LIC 9099-C1...

Allegation: Facility financially abused resident.
The Department conducted records review interviews to investigate this allegation. During interview conducted on 03/17/2023 with ED indicated the money removed from R1's account was from an auto payment that R1 had signed up for during his admission. During interview conducted with R1 indicated facility being dishonest as he had requested a stop on auto payment but facility has failed to complied.

Based on interviews conducted, the preponderance of evidence standards have not been met. Therefore, the above allegations are 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 conducted and a copy of the report and appeal right was provided.

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)

Page: 4 of 4