435202775-7-14-2023-26-AS-RMAO-CUHJKU-20230808070741

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202775
Report Date: 07/14/2023
Date Signed: 07/14/2023 01:49:31 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
06/30/2021 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20210630114224

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: 95	DATE:	07/14/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Ronn Ellenich		TIME COMPLETED:	01:59 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of supervision resulting in resident suffering a fall while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint visit to deliver the investigation finding and met with Executive Director (ED) Ronn Ellenich.

The Department received information regarding resident (R1) residing in Memory Care unit and the resident’s spouse (R2) who is also a resident in the Assisted Living unit was suspected in causing R1’s fall and the facility’s lack of supervision resulted in R1 suffering a fall while in care.

On 7/2/2021, the Department conducted an unannounced initial 10-day investigation. LPA Roadilla interviewed Resident Services Director (RSD), Charmaine Verador. RSD stated the incident was an un-witnessed fall and verified R1 is in Memory Care Unit and R2 resides in Assisted Living Unit.

Continue on LIC9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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 2

Control Number 26-AS-20210630114224

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: 07/14/2023

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

Based on review of R1’s LIC602A Physician’s Report dated 5/26/2021 signed by Physician, R1 has possible Dementia diagnosis and R1's secondary diagnosis is fall risk. According to Physician’s Assessment, resident has impairment/paralysis, is confused/ disoriented, and has sundowning behavior. Physician wrote a note stating spouse is able to store R1’s medications. This document gives an update on R1’s health condition and at this time R1 is considered a “fall risk”.

Based on review of R1’s records, the Incident Report 6/22/2021 stated on 6/22/2021 at 7:25pm during status check rounds, Medication Technician found R1 on the floor by the bed laying sideways, R1 claimed falling out of bed and complained of neck and shoulder pain. R1's spouse arrived shortly to see R1 before R1 left to the hospital. The report stated R2 came to see R1 after the incident occurred.

Based on information gathered, R2’s spouse was accused of physically abusing R1 by R1’s family members. On 6/23/2021, law enforcement conducted a welfare check on R1 at the facility and based on their investigation, the allegations of elder abuse and neglect were determined to be unfounded. Based on the medical records, the treating physician at Kaiser indicated the R1’s injury was consistent with an accidental fall and did not note any signs of abuse or neglect.

Based on interview of S2, staff member observed R1 falling from the bed and did not observe R2 in the R1’s room during the fall. R2 lived in the Assisted living portion of the facility. R2 was unable to access the Memory Care Unit where the R1 lived because it required an access code for entry.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with ED and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2