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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202775
Report Date: 09/18/2024
Date Signed: 09/18/2024 03:46:08 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
10/18/2022 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20221018164411
FACILITY NAME:ATRIA ALMADENFACILITY NUMBER:
435202775
ADMINISTRATOR:KRIS WALUSZKOFACILITY TYPE:
740
ADDRESS:4610 ALMADEN EXPRESSWAYTELEPHONE:
(669) 258-4567
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:240CENSUS: 145DATE:
09/18/2024
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Executive Director, Corey MillerTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Lack of staff supervision resulting in resident injury.
Facility is understaffed.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Simi Rai and Marcella Tarin conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Executive Director, Corey Miller and stated the purpose of today’s visit.

On 10/18/2022, the Department received a complaint with the above allegations. On 10/28/2022, the Department conducted an initial investigation at the facility.

On 10/18/2022, resident (R1) was assessed at Kaiser Emergency Room due to unexplained bumps and scratches appearing on R1's head. It was alleged the facility staff was under staffed and unable to supervision R1 which resulted in R1 sustaining injury to the head.

Continuation on LIC 9099-C, Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
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-20221018164411
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: ATRIA ALMADEN
FACILITY NUMBER: 435202775
VISIT DATE: 09/18/2024
NARRATIVE
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Page 2 of 2.

On 10/21/2022, the Department interviewed Paramedic 1 (P1) who responded on the 911 call made on 10/18/2022. Paramedic 1 stated he/she assessed resident (R1) and the bumps and scratches on R1's head did not indicate R1 had a fall. P1 stated R1 has neurocognitive impairment and R1 was not aware of current surroundings or recall the facility's name.

On 9/18/2024, LPAs interviewed 3 staff (S1-S3) that were working with resident R1 during the time of the complaint. Three of of three staff stated they do not remember the incident on 10/18/2022. Two of the three staff stated R1 would have seizure-like behaviors where R1 would injury themselves during an episode and would be unbalanced when walking with walker around the facility. Two of the three staff stated they are not aware of any other residents or staff that would try to physically hurt R1. Three out of three staff stated they are not sure if the facility was under staffed at the time and they are not sure if the lack of supervision would cause resident to be injured. Three of the three staff stated all residents were checked every hour or every other hour for safety checks and the facility staff do not provide 1:1 care to R1 in October 2022.

Based on review of R1's Physician's Report dated 3/15/2022, R1 had neurocognitive impairment wherein R1 was confused and disoriented and needed assistance with some Activities of Daily Living (ADLs).

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2