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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000389
Report Date: 03/24/2023
Date Signed: 03/24/2023 04:44:17 PM


Document Has Been Signed on 03/24/2023 04:44 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Kimberly Hagen, Executive DirectorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood met with Executive Director (ED), Kimberly Hagen, to conduct a case management visit.

During inspection conducted on 3/24/2023, it was discovered that a written notice regarding change in level of care regarding private duty personnel was not issued to resident (R1) within 2 days after the implementation of new services due to a change of level of care. LPA requested the 2 day written notice for the private duty personnel implemented during today's visit and facility was unable to supply requested document.

Per Health and Safety Code §1569.657(a), a deficiency is being cited on the attached 809-D.

Exit interview was conducted with ED. A copy of this report and appeal rights were provided. The ED’s signature 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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/24/2023 04:44 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: ATRIA EL CAMINO GARDENS
FACILITY NUMBER: 347000389

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/08/2023
Section Cited
HSC
1569.657(a)

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§1569.657 Rate increase due to change in level of resident care; notice (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding H&S Code 1569.657. Facility will submit statement of understanding to LPA by POC due date of 4/8/2023.
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Based on records reviewed, the facility did not ensure that R1 received a 2-day notice of new private duty personnel services implemented, which poses a potential health, safety, and personal rights risk 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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2