435202775-3-18-2022-26-AS-KHOS-CDMV2V-20220419160346

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202775
Report Date: 03/18/2022
Date Signed: 03/18/2022 05:34:37 PM

Unfounded

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
05/14/2021 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20210514144554

FACILITY NAME:	ATRIA ALMADEN		FACILITY NUMBER:	435202775
ADMINISTRATOR:	SHEPODD, PAUL		FACILITY TYPE:	740
ADDRESS:	4610 ALMADEN EXPRESSWAY		TELEPHONE:	(916) 221-8126
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:	05:45 PM

ALLEGATION(S):

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Facility staff do not allow resident's family to attend resident's care meetings
Facility staff did not inform resident's family of resident's condition

INVESTIGATION FINDINGS:

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LPA Marrufo conducted an unannounced complaint investigation visit and met with Assistant Executive Director San Sor. On 05/14/2021, the Department received a complaint investigation with the above allegations. The Department conducted complaint investigation visits on 05/20/2021, 07/02/2021, and 03/15/2022. The Department also conducted interviews and records requests on other dates.

Facility staff do not allow family to attend resident R1’s care meetings

Licensing Program Analyst (LPA) Marrufo conducted a file review of R1’s Resident Face Sheet that included R1’s emergency contacts. The Resident Face Sheet lists R1’s spouse as the Responsible Party and R1’s daughter as the Emergency Contact.

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

Unfounded

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 7

Control Number 26-AS-20210514144554

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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R1’s Admission Agreement was signed 02/18/2021 by both R1 and R1’s spouse. R1’s Physician’s Report from 01/08/2021 stated R1 did not have dementia or mild cognitive impairment and R1 as not being confused/disoriented.

R1’s resident records include a notarized Uniform Statutory Form Power of Attorney letter appointing R1’s spouse as R1’s Power of Attorney (POA). The letter is dated 07/14/2021. The letter grants R1’s spouse all of the powers listed in the letter, including banking and other financial institution transactions, personal and family maintenance, tax matters, real property transactions, and retirement plan transactions.

The Department also obtained copies of R1’s Resident Notes dated from 02/27/2021 until 11/12/2021. The Resident Notes document R1’s spouse, Primary Care Physician, and R1’s daughter being notified of R1’s medical and health incidents.

On 3/16/2022, LPA Marrufo conducted a telephone interview with R1’s child. During interview, R1’s child stated to have not have a Power of Attorney letter signed prior to R1 being admitted into the facility. R1’s child stated that there was an unsigned Power of Attorney letter written with his/her name, but it was unsigned because he/she did not know about the existence of the letter until approximately three weeks after R1’s death. R1’s child stated that the Power of Attorney letter was part of R1’s trust. During interview, R1’s child further stated to have not been aware of R1’s admission into the facility and did not become involved with R1’s care until R1’s spouse had been admitted into a hospital on May 4, 2021 through May 10, 2021.

On 03/16/2022 and 03/17/2022, LPA attempted to conduct telephone interviews with R1’s spouse and daughter but was unable to make contact to conduct an interview.

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: 3 of 7

Control Number 26-AS-20210514144554

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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Facility staff did not inform resident’s family of resident’s condition.

On 02/04/2022, the Department interviewed the former Resident Service Coordinator (RSC). RSC stated that when R1 was admitted to their community, R1’s child or children’s contact information was not provided to them by R1. RSC stated that the community did not have contact with R1’s child/family member; therefore, R1’s child/family member were not involved in any of R1’s care conferences. RSC states that R1’s child/family member were not told to participate in care conferences. RSC states the facility was not in the position to restrict R1’s child/family member from not attending R1’s care conferences. RSC states R1’s spouse has to make the decision to whom to allow to participate in R1’s care conference. R1’s spouse was the responsible person on record. RSC stated that when R1’s child/family member came to visit R1, they came to inquire or discuss about R1’s health condition including R1’s placement to memory care unit.

This agency has investigated the complaint allegations listed. Based on interviews with staff and witnesses and review of records, the Department has found that the complaint allegations are unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

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)

Page: 2 of 7

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
05/14/2021 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20210514144554

FACILITY NAME:	ATRIA ALMADEN		FACILITY NUMBER:	435202775
ADMINISTRATOR:	SHEPODD, PAUL		FACILITY TYPE:	740
ADDRESS:	4610 ALMADEN EXPRESSWAY		TELEPHONE:	(916) 221-8126
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	240	CENSUS:	DATE:	03/18/2022
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	San Sor		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Resident sustained injuries due to multiple falls while in care
Facility staff did not dispense resident's medications as prescribed

INVESTIGATION FINDINGS:

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Resident sustained injuries due to multiple falls while in care

During the investigation, the Department obtained Incident Reports dated 05/14/2021 and 6/22/2021, Resident Assisted Daily Living Report for R1, R1’s Functional Capabilities Assessments dated 02/09/2021 and an updated version dated 05/12/2021, R1’s Resident Notes, and Resident Monthly Completed Tasks dated from May 2021 to November 2021.

The Incident Report dated 05/14/2021 states that facility staff observed R1 sitting on the floor of the living room during a routine safety check. R1 denied to have fallen and appeared to staff to be confused and frustrated. Staff called 911 and resident was transported to the hospital. R1 was evaluated by medical professional and was diagnosed with hip contusion.

See LIC9099-C for more information. Page 1 of 4.

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: 4 of 7

Control Number 26-AS-20210514144554

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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The incident Report dated 06/22/2021, staff states that during a routine status check R1 was found on the floor by R1’s bed. R1 was taken to the hospital by paramedics. This report did not indicate that R1 sustained injury.

On 06/23/2021, law enforcement officers were called or summoned in the facility by R1’s child/family member to report that R1’s fall on 6/22/2021 was due to R1’s spouse neglecting and abusing R1. R1 sustained minor abrasions to the right elbow. R1’s treating physician at the hospital indicated that R1’s injury was consistent with the accidental fall and did not note any signs of abuse or neglect.

LPA reviewed R1’s Assessment records wherein R1 requires stand-by/remind assistance three times per day. Staff confirmed that R1 was put on increased monitoring to ensure R1’s safety and change of condition.

R1’s Resident Notes state that the facility documented and assisted with R1’s falls, including on 04/25/2021, 05/01/2021, 05/04/2021 at 2:00 PM and 7:00 PM, 05/06/2021, 05/13/2021, 05/15/2021, and 05/21/2021. R1’s Resident Activities of Daily Living (ADLs) Report shows entries from 04/27/2021-05/17/2021. The report indicates three entries per day recording staff fall reduction service for R1.

On 02/04/2022, the Department interviewed the former RSC. RSC stated that when R1’s spouse was hospitalized. Facility staff conducted routine checks on R1. During a routine check, RSC stated that staff reported that R1 was observed on the floor twice. RSC stated that he/she was not sure when R1 began having falls. RSC stated he/she did not know if R1 had falls prior to R1’s spouse's hospitalization, or if there were reports from R1’s spouse of R1’s having falls and/or sustaining fall injuries. Review of Resident Notes indicated an entry on 4/25/2021 that R1’s spouse called to report that R1 was seen sitting on the floor beside his/her bed. Paramedics came to evaluate R1. R1 did not sustain skin tear nor a bruise but was noted with a little pain on his/her right cheek. R1 was not sent to the hospital.

The incident report indicates that facility staff contacted R1’s spouse for increased care and medication management and transfer to Memory Care.

See LIC9099-C for more information. Page 2 of 4.

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: 5 of 7

Control Number 26-AS-20210514144554

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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Facility staff did not dispense resident’s medications as prescribed.

R1’s Functional Needs Assessment dated 02/09/2021 indicate R1 was capable of all responsibilities related to medication management, including self-managing medications, ordering medications, and self-administering medications.

On 5/12/2021, R1 was reassessed. According to the assessment, R1 was able to self-manage medication, but not able to tell time/day/month and not able to correctly verbalize time and routes of all medications ordered and states that R1 was not capable of self-administering medications prescribed by the physician but would be receiving assistance from family.

On 02/04/2022, the Department interviewed former Resident Service Coordinator (RSC). RSC stated that when R1 was admitted, R1 was able to manage all aspects of R1’s care including medications. R1 was assessed wherein R1 did not show any signs of dementia. R1’s medication management was not part of R1’s admission agreement. R1’s spouse would remind and assist R1’s medication. RSC stated that during a routine check, while R1’s spouse was at the hospital, staff observed that R1’s medicines were on the table and it appeared to the staff that R1 was not taking them. R1’s spouse was notified and agreed that R1 needed to be assisted with medication for two weeks. R1’s physician was informed about R1’s change of cognition, decreased ability to administer medication, and R1’s falls.

RSC stated that when R1’s spouse was hospitalized on 5/4/2021 (R1’s spouse’s care notes indicate that he/she was hospitalized from 05/4-18/2021), the facility checked on R1. R1 was observed to be confused. Based on R1’s resident notes on 5/5/2021, the Executive Director (ED) and RSC spoke to R1’s child and R1’s spouse’s children about R1’s medication and told them that R1’s family will coordinate medication assistance. RSC stated that the facility did not manage R1’s medication, but instead conducted frequent checks on R1’s well-being and reminded R1 to take medications as of 5/4/2021. RSC stated that Atria has a strict policy on medication management wherein R1 was not under their medication management agreement; therefore, staff can only remind R1 to take his/her medication.

See LIC9099-C. Page 3 of 4.

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: 6 of 7

Control Number 26-AS-20210514144554

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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RSC stated that after a couple of days, R1’s unused medications were found on the table by staff. RSC contacted R1’s spouse and medical doctor (MD) to request an order for medication management. R1’s spouse agreed to put R1 on the facility medication management program. RSC was not aware nor informed by R1’s child/family member about R1’s medication dispenser being full. RSC stated that when the facility discovered that R1 was decompensating with medications, the facility medication technicians were assigned to check on R1 to make sure that R1 takes his/her medication. RSC stated after R1’s spouse discharged from the hospital, R1’s spouse came to the facility to assist with R1’s medication while waiting for MD’s order.
R1’s Resident Notes includes an entry on 05/27/2021 indicating that R1 received a pre-Life Guidance (Memory Care) assessment from Resident Services Director (RSD) and R1 was designated as ALZ1, which includes care and medication management, per interview with current Assistant Executive Director on 03/18/2022. R1’s resident records also include a Room Change Addendum and Life Guidance Program Secured Environment Addendum, both signed by R1’s spouse on 05/30/2021. Both addendums were necessary for transitioning R1 into Memory Care.

Seven staff were asked during interviews with the Department if the facility provided R1 with medication assistance. Six out of seven staff stated the facility did provide R1 with medication assistance and one out of seven staff stated to be not aware of the issue.

During interview, R1’s child stated that R1 did not require assistance with medications when R1 was admitted to the facility. R1’s child stated that during the time when R1’s spouse was hospitalized away from the facility, around May 5th-9th, 2021, R1’s child visited R1 at the facility. R1’s child stated that during his/her visit to R1, R1 verbalized having refused medications. R1’s child also stated to have observed R1 falling asleep while eating.

Based on information from interviews conducted with staff and witnesses and review of records, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22

This report was reviewed with AED San Sor and a copy of the report was provided. Page 4 of 4.

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: 7 of 7