435202775-3-18-2022-26-AS-RMAO-CDASGF-20220408135152

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202775
Report Date: 03/18/2022
Date Signed: 03/18/2022 05:55:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2022 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20220127151401

FACILITY NAME:	ATRIA ALMADEN		FACILITY NUMBER:	435202775
ADMINISTRATOR:	WESLEY WHITTEMORE		FACILITY TYPE:	740
ADDRESS:	4610 ALMADEN EXPRESSWAY		TELEPHONE:	(669) 258-4567
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	240	CENSUS: 73	DATE:	03/18/2022
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	San Sor		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Facility violated resident's personal rights.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted a complaint investigation visit to deliver investigation finding of the above allegation. LPA met with Assistant Executive Director San Sor.

On 01/27/2022, the Department received a complaint that the facility violated resident's personal rights by ensuring that a power of attorney was executed by a resident that had capacity.

On 02/01/2022, LPA Steve Chang interviewed Community Business Director (CBD). CBD stated that the facility did not receive a copy of the Power of Attorney (POA) from R1 prior to R1’s admission to the facility; they both resided in the Assisted Living Unit until R1’s health deteriorated and subsequently transferred to Memory Care unit in 05/31/2021.

See LIC9099-C for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

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 3

Control Number 26-AS-20220127151401

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ATRIA ALMADEN	FACILITY NUMBER: 435202775
	VISIT DATE: 03/18/2022

NARRATIVE

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Prior to R1’s admission/transfer to the memory care unit, the facility had requested to obtain a Power of Attorney (POA) from R1’s spouse which is needed due to R1’s neurocognitive disorder (diagnosis of dementia). On 07/14/2021, R1’s spouse obtained and provided a copy of R1’s POA to the facility. CBD stated that R1’s child or family member did not provide them a copy of his/her/their POA as R1’s agent.

On 02/03/2022, the Department interviewed Engaged Life Director (ELD), who confirmed receiving a copy of R1’s POA from R1’s spouse but not from R1’s child/family member which also confirmed by Resident Service Coordinator (RSC) on 2/4/2022. ELD stated that R1’s child/family member was not involved in R1’s care and supervision; rather, it was R1’s spouse who was very involved in R1’s care and supervision including finances until R1’s death.

On 3/16/2022, LPA Marrufo interviewed R1’s child/family member who stated that he/she was not aware of having been appointed by his/her mother (R1) as R1’s POA agent for R1’s finances as stipulated, “… has the duty to act unless you and your agent agree otherwise in writing. This document gives your agent the powers to manage, dispose of, sell and convey your real and personal property, and to use your property as security if your agent borrows money on your behalf…” (page 6-1).

R1’s notarized POA was not signed by R1’s child/family member. R1’s child/family member was unaware of R1’s POA not until or after R1’s death in November 2021. R1’s child/family member also noted that he/she was not involved in any financial affairs and medical care of R1. R1’s child/family member stated that R1’s spouse was responsible for R1’s medical decisions and finances.

See LIC9099-C for more information. Page 2 of 3.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20220127151401

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ATRIA ALMADEN	FACILITY NUMBER: 435202775
	VISIT DATE: 03/18/2022

NARRATIVE

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Based on comparing R1’s notarized POA obtained from R1’s spouse and the POA from R1’s child/family member, it is determined that both POA letters are similar. Neither R1’s spouse nor R1’s child/family member are appointed to be R1’s advance health care agents. The facility had a validly executed Power of Attorney letter that was signed and notarized in R1’s resident file. R1’s child stated during interview to not have had knowledge of the POA letter signed by R1 in 2015 and only became aware of the POA letter approximately three weeks after R1’s death.

Based on available information through interviews and record reviews, the allegation on personal rights is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

This report was reviewed with Assistant Executive Director San Sor and a copy of the report was provided.

See LIC9099-C for more information. Page 3 of 3.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

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