347000389-10-20-2023-59-AS-CYAG-CWSVNU-20231020163543

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347000389
Report Date: 10/20/2023
Date Signed: 10/20/2023 04:36:01 PM

Document Has Been Signed on 10/20/2023 04:36 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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: 192	DATE:	10/20/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Kim Hagen		TIME COMPLETED:	12:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/20/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced to conduct a case management visit regarding the incidents reports the Department received on Tuesday October 17, 2023. LPAs met with Executive Director (ED), Kim Hagen, and explained the purpose of the visit. LPAs and ED discussed the serious/unusual incident report (SIR) submitted for an incident occurring on 9/10/2023 regarding R1’s emotional distress. LPAs discussed the importance of submitting SIRs in a timely manner as Title 22 mandates written reports to be submitting within seven days of occurrence. ED explained the dated of occurrence was inputted incorrectly as the incident occurred on 10/15/2023 not 9/10/2023. Additionally, LPAs and ED discussed the SIR submitted for an incident occurring on 10/16/2023 regarding the incident with medications in R2’s room. LPAs discussed the importance of informing family members that medications are to be locked and secured if resident is able to store own medications. ED informed LPAs R2 is a new resident in care, and is in the Med Program, meaning facility assist with medication administration. ED stated the medications found in the room where over the counter medications which was removed during time of observation. ED informed LPAs the facility notified family members immediately to remind them of facility's protocols. ED also stated primary care physician was notified as all medications need a doctor's order. LPAs and ED then discussed the LIC 624A Death Report received for R3. ED informed LPAs R3 was hospitalized beginning of the month due to a concern home health nurse observed. ED stated R3 was then discharged to a skilled nursing facility and then hospitalized again for the original concerns when R3 was at the facility. ED stated cause of death is unknown as R3 has not been at the facility for a few weeks. Please continue on LIC 809-C...

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ATRIA EL CAMINO GARDENS	FACILITY NUMBER: 347000389
	VISIT DATE: 10/20/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LIC 809-C...

At this time, LPAs requested a copy of R3's LIC 602, Emergency Contact, Needs and Assessment, all 2023 Incident Reports, list of meds, and Power of Attorney documents. LPAs informed ED to submit a copy of R3's Death Certificate once received by the family. This incident will be under review until further notice by the Department.

During this visit, no deficiencies cited.

Exit interview conducted and a copy of the report was provided to ED.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2