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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200326
Report Date: 03/25/2026
Date Signed: 03/25/2026 04:16:58 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/20/2026 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20260320102443
FACILITY NAME:ATRIA PARK OF LAFAYETTEFACILITY NUMBER:
079200326
ADMINISTRATOR:WOOLBRIGHT, JONATHAN MFACILITY TYPE:
740
ADDRESS:1545 PLEASANT HILL RDTELEPHONE:
(925) 932-9910
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:130CENSUS: 98DATE:
03/25/2026
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Executive Director Jonathan WoolbrightTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Lack of supervision resulting to resident sustaining injury from assault by another resident.
INVESTIGATION FINDINGS:
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On 03/25/2026 at 02:45 PM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct an initial 10-day complaint investigation and to deliver findings regarding the allegation above. LPA met with Executive Director Jonathan Woolbright and explained the purpose of the visit.

During the course of the investigation, LPA obtained copies of Physician’s Reports, Appraisal Needs and Services Plans, After Visit Reports, Unusual Incident Report LIC624, and the Identification and Emergency sheets for two (2) residents. LPA interviewed two residents, three (3) staff, and one (1) one-on-one care provider.

Allegations: Lack of supervision resulting to resident sustaining injury from assault by another resident.

Investigation Findings: It was reported to the department that R1 was brought by an ambulance with a complaint of left shoulder, left forearm and left leg skin tears with left hip pain post "assault by another resident”. RP reported that Charge RN Grace at Atria, informed RP that R1 was found on a floor in room with another resident In the room on 3/19/26 at 4:30AM. Both residents are from the memory unit. S2 reported that in the early morning hours on the day of the incident, staff reported that R1 called out for help after falling. Upon arrival R1 was seen on the floor with skin tears on left elbow and left knee consistent with a fall.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
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 15-AS-20260320102443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ATRIA PARK OF LAFAYETTE
FACILITY NUMBER: 079200326
VISIT DATE: 03/25/2026
NARRATIVE
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Continued from LIC9099

The caregiver then called for assistance from the night shift nurse as the caregiver saw R2 in R1’s bathroom. S1, S2, S3 informed LPA that protocol for a fall is for staff to call 911 for any unwitnessed fall. As the night shift nurse called 911 and assisted R1, the caregiver then tried to redirect R2 out of R1’s bathroom. R2 informed the caregiver that R2 was trying to find the bathroom and did not want to leave the bathroom due to R2’s urgent need. The caregiver was able to redirect R2 out of R1’s room and into a public bathroom nearby. Paramedics arrived, addressed R1’s skin tears, and took R1 to the Emergency Room. The paramedics also took R2 to the Emergency Room for evaluation. No Urinary Tract Infection noted for R2.

R1 has a history of skin tears due to falls as noted in R1’s medical records and a history of Dementia. R1 Physician’s Report shows R1 has thin skin prone to tears. R1 does require assistance with toileting, wears diapers, but will still try to use the toilet on R1’s own. S1, S2, and S3 all informed LPA that R1 has a history of getting up at night to use the toilet and falling. R1 uses a wheelchair but will still try to walk on own thus causing R1 to fall. Staff have been monitoring R1’s sleep patterns to assist with toileting needs and encourage R1 to ask for assistance before getting up. R1 was brought back to the facility the next day with bandages covering the skin tears. No bruising or signs of physical abuse noted on the After Care Summary. LPA interviewed R1. R1 had no recollection of the incident. R1 did still have bandages on the skin tears. R1 could not recall why the bandages were there. R1 informed LPA R1 feels safe in the community.

R2 moved into the facility two days prior to the incident. S2 noted the R2 had not slept the first full night, and very little the next. R2 was still very unfamiliar with the facility on the day of the incident. S3 did the initial move in assessment. S3 reported R2 showed no signs of aggression prior to moving in. S1, S2, and S3 all reported R2 being polite, easy going, and non confrontational with staff or fellow residents. After returning from the Emergency Room, S2, and S3 both suggested R2’s family hire a one-on-one care provider as R2 was still having difficulties sleeping and adjusting to new surroundings. LPA interviewed R2. R2 had family over who stayed in the room during the interview. R2 had no recollection of the incident. R2 reported still getting use to the facility, but enjoys it. LPA met R2’s one-on-one care provider, S4< who reported S3 being polite and respectful.

Continued on LIC9099-C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20260320102443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ATRIA PARK OF LAFAYETTE
FACILITY NUMBER: 079200326
VISIT DATE: 03/25/2026
NARRATIVE
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Continued from LIC9099-C

LPA toured the memory care unit. LPA observed R1’s room is close to a common bathroom and to R2’s room. Residents in the memory care unit do not usually have their doors closed as confirmed by S2. It would therefore not be unreasonable for a resident with dementia and new to the facility to get confused and walk into the wrong room while looking for a bathroom. R1 did have an unwitnessed fall, and R2 happened to walk in at the same moment.

LPA reviewed the staff schedule. There are two Resident Services Assistants and one nurse on night shift for memory care. All were working that morning. No resident before the day of the incident required a one-on-one care provider. LPA determined sufficient staffing needs were met on the day of the incident.

Based on interviews and record review conducted, the above allegation is unsubstantiated.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy this report was provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3