347000389-8-30-2021-25-AS-MLLS-C6DQTH-20210830122711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347000389
Report Date: 08/30/2021
Date Signed: 08/30/2021 12:27:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	ATRIA EL CAMINO GARDENS		FACILITY NUMBER:	347000389
ADMINISTRATOR:	RIST, ALICIA		FACILITY TYPE:	740
ADDRESS:	2426 GARFIELD AVE		TELEPHONE:	(916) 488-5722
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	325	CENSUS: 218	DATE:	08/30/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Administrator, Alicia Rist		TIME COMPLETED:	12:30 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	Licensing Program Analysts (LPAs) Melana Llopis and Kevin Mknelly arrived at the facility unannounced on 08/30/2021 to conduct a Case Management- other visit. Prior to visit, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; upon entry completed a facility risk assessment. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Masks. Additionally, LPAs were screened by Vanessa Jones, staff, upon entering the facility. LPAs met with Administrator, Alicia Rist and explained the purpose of the visit was to deliver additional civil penalties regarding the findings delivered on 04/08/2020. On April 8, 2020, the Department concluded a complaint investigation and substantiated an allegation that the facility staff failed to respond to resident's call button in a timely manner. The resident (R1) was later found deceased when staff arrived. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87468.2(a)(8)- Additional Personal Rights of Residents in Privately Operated Facilities (a)(8) “In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse” as R1 had called for assistance approximately 40 minutes before staff responded to R1’s call. *Continuation on LIC809-C*

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ATRIA EL CAMINO GARDENS	FACILITY NUMBER: 347000389
	VISIT DATE: 08/30/2021

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

During the course of the investigation, the Department conducted interviews, obtained and reviewed copies of R1’s residential file and facility policy documentation. According to interviews, the Department learned two (2) of four (4) staff scheduled to work on December 22, 2019 had called in and did not work. These staff were scheduled to work during the nocturnal shift on December 22, 2019. Interviews revealed lack of staffing made it difficult for the staff working on December 22, 2019 to respond timely to R1' emergency call devices. The Department reviewed call log records for December 22, 2019 and observed several residents, waited in excess of twenty-five (25) minutes. Interviews indicated the current staff had stayed at work to cover the shifts for those employees who were absent on the evening of December 22, 2019. The Department also learned there are typically four (4) staff members working and available to assist residents. On December 22, 2019 staff interviews indicated that during the time of R1’s calls, three (3) of the staff were in the medication room conducting medication count and one (1) staff was on the floor responding to resident calls.

According to multiple staff interviews, staff (S4) responded to the assisted living section of the facility where R1 resides. S4 found R1 unresponsive at approximately 10:59 p.m., on the floor and contacted staff (S3) to assist. When S3 arrived, S3 contacted S2 and S5 to assist. S2 contacted emergency services. According to staff interview, the call for emergency services for R1 was made at approximately 11:00 p.m.

The Department reviewed R1's Emergency Call Device Log. The Resident Emergency Call Device Log indicates a history of calls made by residents using this device. The log for December 22, 2019, indicates that R1 had pushed the emergency call device at 10:19 p.m. and attempted seven (7) more times following the initial request for emergency assistance. The log also provides information showing that staff responded to R1's call at 10:59 p.m., which was 40 minutes after R1 made the initial call for assistance.

The Resident Emergency Call Devices policy, which was made effective on February 14, 2014 states “Assisted Living staff will respond to the resident's emergency device within a timely manner. A timely response is 5 to 10 minutes for an occupied building for 99 residents or less, 10 to 15 minutes for 100 plus residents." Additionally, according to the facility policy regarding Resident Emergency Call Devices, the response time for California facilities should not exceed 20 minutes. According to recent census, the facility has 242 residents in care.

***Continuation on LIC809-C***

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ATRIA EL CAMINO GARDENS	FACILITY NUMBER: 347000389
	VISIT DATE: 08/30/2021

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

A May 22, 2018 citation (the third such citation in three years) for the same violation, CCR Title, 22 § 87411(a), had a plan of correction which called for the licensee to review and update the plan for responding to resident pendant calls in an amount of time to meet the resident’s needs, as well as proof of training for all staff. The updated plan was to include clear direction relative to who is responsible for reviewing the staff log; the daily call records for possible lapses in logging by staff; as well as ensuring a clear record of review of incidents with corrective actions are being taken. This information was not presented to the Department during this investigation.

The Department requested and reviewed a copy of the signed Admission Agreement dated October 31, 2018 belonging to R1. In the Admission Agreement there is language regarding the emergency call system that states that a "Call will alert a member of our Resident Care team who will promptly report to your apartment upon receiving the call for emergency assistance.”

The Department requested and reviewed the local County Sheriff's Department incident report, which indicated the incident was "regarding a deceased subject with possible elder neglect". The incident report references the Fire Event Report.

The Department requested and reviewed the local Fire District Incident Report dated December 22, 2019 and the call for services was at 23:01 hours (11:01 p.m.). The Fire Department arrived at the facility at 23:06 hours (11:06 p.m.). The report states upon arrival staff was performing chest compressions on R1 who was unresponsive. The report revealed staff at the facility stated they were unable to respond to R1's alarm for approximately 25 minutes before finding R1 unresponsive on the ground. The incident report also states that life-saving care was initiated, including cardiopulmonary resuscitation (CPR), intravenous (IV) medications, and intubation. R1 was transported to the hospital and was declared deceased upon arrival at the hospital.

The Department obtained and reviewed audio recordings of 9-1-1 emergency call from Sacramento Regional Fire/EMS Communication Center. Audio obtained was pertinent to the incident on December 22, 2019 for 2426 Garfield Ave. The audio recording revealed that S2 contacted Emergency Medical Services prior to entering R1's room, as S4 and S3 had responded to R1's call for assistance. When S2 arrived in R1's room, S2 provided chest compressions, while on the 9-1-1 call, for approximately eight (8) minutes until paramedics arrived.
***Continuation on LIC809-C***

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ATRIA EL CAMINO GARDENS	FACILITY NUMBER: 347000389
	VISIT DATE: 08/30/2021

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

Interviews indicate that there were four (4) staff present during the incident on December 22, 2019, however, only one (1) of the four (4) (S4) were providing caregiver responsibilities and responding to residents' calls for assistance, while the other three (3) staff were responsible for med tech duties. Also, according to interviews, if a caregiver is unable to respond to the third call a resident makes on their push button, the calls will then go to a med tech. However, at the time of the incident, the med techs were performing med tech duties and were unable to assist with caregiver responsibilities.

Based on observation, interviews, and record review, the licensee did not ensure a sufficient number of staff to meet resident needs in a timely manner, which resulted in the death of a resident.

At the time of the complaint visit on April 8, 2020, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for the death of a resident.

Today, August 30th 2021, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the department determines resulted in the death of a resident in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on April 8, 2020 the amount of the civil penalty issued today will be $14,500.

A copy of the LIC 421D was given to Administrator, Alicia Rist and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Administrator signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana Llopis	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4