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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000389
Report Date: 10/27/2021
Date Signed: 10/27/2021 03:47:17 PM

Document Has Been Signed on 10/27/2021 03:47 PM - It Cannot Be Edited

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 GARDENSFACILITY NUMBER:
347000389
ADMINISTRATOR:RIST, ALICIAFACILITY TYPE:
740
ADDRESS:2426 GARFIELD AVETELEPHONE:
(916) 488-5722
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 325CENSUS: 205DATE:
10/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Barbara Fleck, Assistant Executive DirectorTIME COMPLETED:
03:55 PM
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Licensing Program Analysts (LPAs) Angela Hood and Michael Hood arrived at the care home today and met with the Assistant Executive Director, Barbara Fleck, to conduct a case management visit. LPAs wore an N95 masks and were screened upon entry in the care home. All staff wore masks and there are no COVID positive cases at the facility.

During a file review and interview previously conducted, it was discovered that a 30-day written notice to terminate issued to resident (R1) was not provided to CCLD. Facility staff were unable to locate any documentation indicating that the 30-day written notice to terminate was submitted to CCLD. LPA reviewed the Department's internal databases and could not locate the 30-day written notice to terminate that was issued to R1.

Due to the information above, per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 809-D page.



Exit interview was conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2021 03:47 PM - It Cannot Be Edited


Created By: Angela Hood On 10/27/2021 at 03:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ATRIA EL CAMINO GARDENS
FACILITY NUMBER: 347000389

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2021
Section Cited
CCR
87224(f)

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87224 Eviction Procedures (f) A written report of any eviction shall be sent to the licensing agency within five (5) days.

This requirement is not met as evidenced by:

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Facility shall submit a statement of understanding to LPA by the POC due date of 11/10/21.
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Based on records reviewed and interview conducted, the facility did not ensure they submitted the 30-day written notice to terminate R1 to CCLD, which poses a potential health, safety, and personal rights risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Maribeth Senty
LICENSING EVALUATOR NAME:Angela Hood
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
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