Atria San Juan

Allegation investigated: Facility staff did not follow resident's admission agreement Facility staff did not shower resident as needed Facility staff handled resident in a rough manner Facility staff did not ensure resident had clean bed linens Facility staff did not respond to resident's calls for assistance in a timely manner

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Executive Director James Craddock and explained the reason for the visit. The investigation into the allegation, facility staff did not follow resident's admission agreement, revealed the following. It was reported that facility did not check on Resident 1 (R1) every 2 hours, did not escort resident to breakfast, lunch and dinner, and assist R1 with toileting and dressing. A review of R1's care plan shows R1 did not require assistance with toileting. R1's care plan shows R1 was not on 2 hour checks. As of July 22, 2025 R1 was put on hourly checks due to agitation and wandering. 4 out of 4 staff reported that R1 was helped with dressing daily but sometimes refused to change their clothes. R1's care plan shows R1 required escorting to all meals, breakfast, lunch and dinner. 4 out of 4 staff reported that R1 was always escorted to all meals. Unsubstantiated The Life Guidance Director reported that they are unaware of R1 missing any meals. Witness 1 (W1) reported they had video footage proving the allegation, but it was never provided. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation, facility staff did not follow resident's admission agreement, is unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, facility staff did not shower resident as needed, revealed the following. It was reported that R1 only received 3 showers in a 3 and a half week period. R1 moved into the facility on July 3, 2025, and moved out on July 24, 2025. W1 reported that R1 was suppose to receive 3 showers a week but did not receive them. R1 was moved into memory care on July 11, 2025 due to wandering behaviors and to have more supervision. 4 out of 4 staff reported that R1 was combative and always refused showers when approached. 4 out of 4 staff reported that they asked R1 later if they wanted to shower and R1 usually agreed. None of the staff interviewed remember a specific day or time R1 missed a shower. R1 moved out of the facility and their location is unknown so they could not be interviewed. Facility does not keep shower records. 4 out of 4 staff reported they do not know how many showers R1 received during their stay at the facility. The Life Guidance Director reported that staff do all they can to make sure residents are showered regularly but in the case of R1, R1 could be combative and hit staff so if R1 refused a shower and hit staff they could have missed a shower even though the facility attempted to provide one. All staff interviewed reported that if someone missed a shower they would attempt to provide one the next day. None of the evidence gathered supports the allegation. Based on the evidence gathered the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, facility staff handled resident in a rough manner, revealed the following. It was reported that Staff 1 (S1) handled R1 in a rough manner. No dates or times were provided for when S1 handled R1 in a rough manner. W1 reported there was video footage of S1 handling R1 in a rough manner. No video footage was ever provided. S1 denied the allegation. 4 out of 4 staff interviewed including S1 reported that they have never witnessed any resident being handled in a rough manner. The Life Guidance Director reported they were unaware of any resident being handled in a rough manner and have never witnessed any resident being handled in a rough manner. R1 moved out of the facility and their location is unknown so they could not be interviewed. Based on the evidence gathered the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, facility staff did not ensure resident had clean bed linens, revealed the following. It was reported that R1 had urine soaked sheets that were not changed. W1 reported that R1's sheets were soiled with urine and Staff 1 (S1) made R1's bed and left the soiled sheets on the bed and they were not changed until the next day. No dates or times for this incident were provided. W1 reported they had video footage of the incident but it was never provided. S1 denied the report. 4 out of 4 staff interviewed including S1 reported that beds would never be made with soiled sheets and all bedding is changed when it is soiled. 4 out 4 staff interviewed including S1 reported that bedding is changed regularly for all residents. During the initial 10-Day visit LPA inspected resident rooms and did not observe any soiled linens in resident rooms. Based on the evidence gathered the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, facility staff did not respond to resident's calls for assistance in a timely manner revealed the following. It was reported that R1 fell on July 21, 2025, at 2:15 am and was on the floor until 5:00 am and facility staff did not respond to R1's call for help in a timely manner. Witness 1 (W1) reported they had video footage to prove the allegation but it was never provided. A review of facility records shows that on R1's progress notes, R1 had been put on 1 hour status checks on July 21, 2025, due to agitation. The records show that R1 was checked at 2:00 am on July 22, 2025 and then at 3:00 am R1 was found on the floor. Staff called 911 and R1 was transported to the hospital. Staff 1 (S1) who was present at the facility at the time of the incident reported that they did not hear R1 or any resident call for assistance. A review of call logs for the signal system shows that R1 did not hit the call button in their room. The facility reported the incident to R1's responsible party and the Agency. The incident report shows R1 fell on July 22, 2025. Based on the evidence gathered the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 22-AS-20250728090508

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Executive Director/Administrator (ED) James Craddock and explained the reason for the visit. James Craddock's Administrator's Certificate expires on November 8, 2026. Facility is licensed for 140 non-ambulatory residents with a hospice waiver for 10. The facility is composed of two buildings connected by a hallway. The main building (building B) is 3 stories and houses the memory care unit on the second floor. The secondary building (building A) is two stories. Building B has an interior outdoor courtyard with a water fountain. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA and ED toured the facility. LPA observed the kitchen and dining room are clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Emergency food and water are stored in a storage room next to the kitchen. LPA observed a 3 day emergency supply of food and water. LPA observed the TV/Library room on the first floor. There is a large screen TV, books and magazines and games for residents. LPA and ED toured 10 resident rooms. All 10 resident rooms had the required furnishings. All rooms inspected had clean and operational bathrooms. Hot water measured 108.8 degrees Fahrenheit to 118.0 degrees Fahrenheit in all 10 bathrooms inspected. LPA observed all the fire extinguishers throughout the facility are fully charged. The facility has 4 stairways, 2 in each building. LPA observed and emergency evacuation chair at each stairway. The last emergency drill was conducted on April 9, 2026. LPA observed medication is kept locked in a cart in the medication room. The first aid kit in the medication room has all the required elements. LPA and the Executive Director toured the second floor memory care. LPA tested the delayed egress doors in memory care unit. Both delayed egress doors tested operational. LPA observed shaded outdoor seating next to the dining room and in the interior courtyard. No obstacles or hazards observed inside or outside of the facility. During the visit LPA observed residents participating in card games in the TV/Library room. There is a computer with internet access in the TV/Library room that is dedicated for resident use. LPA interviewed 4 staff and 4 residents. LPA reviewed 7 staff files. All staff are background cleared and associated to the facility. All staff files reviewed had the required training. LPA verified that there is staff on each shift that have CPR training. No discrepancies observed in the staff files. LPA reviewed 10 resident records and medications. No deficiencies are being cited as a result of this visit. An exit interview was conducted with the Executive Director and a copy of the report provided.the state’s words, verbatim · CDSS document, May 12, 2026

Allegation investigated: Staff refused to provide lift assistance to residents in care

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director James Craddock and explained the reason for the visit. The investigation into the allegation, staff refused to provide lift assistance to residents in care, revealed the following. It was reported that residents fell on March 30, 2026, and April 11, 2026, there were no injuries and 911 was called only to provide lift services for both residents. A review records show, on March 30, 2026, Resident 1 (R1) fell and 911 was called by staff. The special incident report (SIR) dated March 30, 2026, shows R1 fell at around 5:15 am and staff called 911. Staff reported it was unknown if the resident hit their head so 911 was called. The SIR states that the family was notified and refused transport of R1 to the hospital. R1's responsible party verified this report. The paramedics assisted the resident off the floor and because transport to the hospital was refused, left the facility. The SIR dated April 11, 2026, reported that Resident 2 (R2) fell around 4:00 am and 911 was called and R2 reported they were in pain. R2 was transported to the hospital. Unsubstantiated 4 out of 4 staff interviewed reported they call 911 if required and 911 is not called for lift assistance. LPA contacted the Orange County Fire Authority but the First responders who responded to the calls were not available for interview. The Administrator reported that in memory care 911 is called in case of head injury that the resident may not be able to report. Both incidents listed above took place in memory care. 4 out of 4 staff interviewed reported that they would assist residents off the floor after a fall if there are no injuries and no signs of head injury and the resident is not in pain. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 22-AS-20260414154752

Allegation investigated: Resident was malnourished while in care. Resident is not accorded privacy during visits. Staff did not safeguard resident's personal items. Facility is not providing activities for residents.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Community Business Director, Christian Woollard, and explained the reason for the visit. The investigation into the allegation, facility is not providing activities for residents revealed the following. It was reported that the activities on the activities calendar are not conducted. Resident 1 (R1) resides in memory care. The activities calendar shows activities every day of the week for assisted living and memory care. The memory care director reported that they have music activities where residents can listen to music or they can bowl with plastic pins, and they have card games for the residents. Witness 1 (W1) reported that no activities are conducted, but no other details were provided. LPA observed that during the initial 10-day visit bingo was being conducted and residents were sitting 6 feet apart from each other. Unsubstantiated In memory care staff were assisting residents with playing individual card games while other residents were listening to music. The Executive Director and the Activities Director reported that activities are always provided but many residents choose not to participate, which makes it very challenging for staff. 3 out of 4 residents interviewed reported that they have participated in activities at the facility. Based on the evidence gathered the allegation, is unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff did not safeguard resident’s personal items, revealed the following. It was reported that Resident 1 (R1) had their phone taken from them. The Administrator reported that R1’s responsible party refused to have R1’s items inventoried. The Administrator stated that they do not know what items R1 moved in with. Staff 1 (S1) reported that R1’s phone was found outside of their room, so they contacted R1’s responsible party and informed them. S1 reported that they didn’t think R1 could use the phone, so they contacted the responsible party. S1 reported that nothing was done to the phone, and it was given to R1’s responsible party in the condition it was found. R1’s responsible party stated that staff did give the phone back but there were new applications on the phone. R1’s responsible party would not answer any further questions during the investigation. 4 out of 4 staff interviewed reported that when residents’ belongings are found they are turned into lost and found until someone claims them. S1 reported that residents in memory care misplace or lose items, and they give it back to the resident or contact the responsible party. No other items were reported missing. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, Resident is not accorded privacy during visits, revealed the following. It was reported that during visits with R1 the family was not given privacy and visits were only allowed in the resident's room 2 times. At the time of the report, visits were allowed at facilities as long as Covid-19 precautions were implemented such as social distancing and wearing masks as outlined in PIN 21-17.1-ASC dated April 23, 2021 and PIN 21-17.2-ASC dated May 14, 2021. The Executive Director reported that all visitors are given privacy and had the choice of visiting in residents’ rooms, in the common areas or outside. 4 out of 4 staff interviewed reported that none of the visitors were denied access to residents' rooms or denied privacy on visits. R1’s responsible party did not answer any questions regarding visitation. 4 our of 4 residents interviewed reported they have always been given privacy during their visits. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, resident was malnourished while in care, revealed the following. It was reported that R1 lost 18 pounds during their stay at the facility and was not fed properly. 4 out of 4 staff interviewed reported that Resident 1 (R1) ate and had no issues with food. The Executive Director reported that R1’s responsible party requested meal logs showing R1 was eating and they were provided. A review of the records shows R1 ate breakfast lunch and dinner during their time at the facility from May 1, 2021 to May 18, 2021. On May 19, 2021 R1’s responsible party had R1 sent to Newport Bay Hospital. R1’s physician’s report showed R1 weighed 200 lbs. on April 5, 2021. Newport Bay Hospital closed on February 22, 2023 so no records are available to compare R1’s weight. R1’s where abouts are unknown. No evidence was gathered to support the allegation, therefore the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Sep 23, 2025 · control 22-AS-20210621132714

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Executive Director (ED) James Craddock and explained the reason for the visit. James Craddock's Administrator's Certificate expires on November 8, 2026. Facility is licensed for 140 non-ambulatory residents with a hospice waiver for 10. The facility is composed of two buildings connected by a hallway. The main building (building B) is 3 stories and houses the memory care unit on the second floor. The secondary building (building A) is two stories. Building B has an interior outdoor courtyard with a water fountain. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA and ED toured the facility. LPA observed the kitchen and dining room are clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Emergency food and water are stored in a storage room next to the kitchen. LPA observed the TV/Library room on the first floor. There is a large screen TV, books and magazines and games for residents. LPA and ED toured 9 resident rooms. All 9 resident rooms had the required furnishings. All rooms inspected had clean and operational bathrooms. Hot water measured 105.0 degrees Fahrenheit to 120.2 degrees Fahrenheit in all 9 bathrooms inspected. LPA observed all the fire extinguishers throughout the facility are fully charged. The facility has 4 stairways. LPA observed and emergency evacuation chair at each stairway. The last fire drill was conducted on April 15, 2025. LPA observed medication is kept locked in a cart in the medication room. The first aid kit in the medication room has all the required elements. LPA and the Executive Director toured the second floor memory care. . LPA tested the delayed egress doors in memory care unit. Both delayed egress doors tested operational. LPA observed shaded outdoor seating next to the dining room and in the interior courtyard. No obstacles or hazards observed inside or outside of the facility. During the visit LPA observed residents participating in a trivia activity in the TV/Library room. There is a computer with internet access in the TV/Library room that is dedicated for resident use. LPA interviewed 4 staff and 4 residents. LPA reviewed 6 staff files. All staff are background cleared and associated to the facility. All staff files reviewed had the required training. No discrepancies observed in the staff files. LPA reviewed 9 resident records and medications, no discrepancies were observed. No deficiencies are being cited as a result of this visit. An exit interview was conducted with the Executive Director and a copy of the report provided.the state’s words, verbatim · CDSS document, May 1, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. The Agency (CCL) received a report from the facility on April 29, 2025 that a resident (R1) could have been abused during the administering of their medication on April 28, 2025, The report stated that while receiving medication Staff 1 could have forced their finger to open R1's mouth to administer their medication. Staff 2 was assisting R1 with putting on their shoes while Staff 1 was attempting to administer medication to R1. R1 bit Staff 1 while they attempted to administer medication with an oral syringe. Staff 1 immediately stopped what they were doing and left. R1 suffered no injuries. Staff 2 who witnessed the incident reported it to the memory care director who informed the Administrator. The Administrator contacted Law enforcement who arrived around 11:00 am. The Administrator reported that the responsible party (RP) and the primary care physician (PCP) for R1 were notified about incident. The Administrator reported that Law Enforcement took no action. LPA interviewed staff and attempted to interview R1 but R1 would not respond to LPA. After the incident R1 was assessed by a Physician's Assistant and no injuries were noted. Based on staff interviews, R1 bit Staff 1 when Staff 1 attempted to administer medication with an oral syringe. None of the evidence gathered through interviews shows any type of abuse toward R1 occurred. Staff reported that the medication had been administered via oral syringe to R1 numerous times without incident. No deficiencies are being issued as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, May 1, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Executive Director James Craddock, who's Administrator's certificate expires on November 8,2024, and explained the reason for the visit. LPA and the Executive Director toured the facility. The facility is composed of two buildings connected by a hallway. The main building (building B) is 3 stories and houses the memory care unit on the second floor. The secondary building (building A) is two stories. Building B has an interior outdoor courtyard with a water fountain. LPA observed the PUB 475 poster (See Something, Say Something) is posted in the main entrance of the facility. LPA observed during the tour that all 4 stairways had emergency evacuation chairs. LPA observed each floor of each building had a working carbon monoxide detector. LPA observed all fire extinguishers are fully charged. LPA observed that the smoke detectors in all 10 rooms that were inspected were operational. LPA measured the hot water in rooms inspected. Hot water measured between 109.0 degrees Fahrenheit to 112.6 degrees Fahrenheit. LPA observed all resident rooms had the required furnishings. LPA observed the fireplace in the resident library is screened. LPA and the Executive Director toured the dining room and kitchen. LPA observed a 2-day perishable and a 7-day nonperishable food supply on hand in the kitchen. LPA observed the kitchen is clean and organized. LPA observed the emergency food stored in a supply closet and the emergency water supply is stored in a storage room. LPA and the Executive Director toured the second floor memory care. LPA observed the medication cart is locked and kept in the life guidance med room. LPA tested the delayed egress doors in memory care unit. Both delayed egress doors tested operational. LPA observed shaded outdoor seating next to the dining room and in the interior courtyard. No obstacles or hazards observed inside or outside of the facility. During the visit LPA observed residents participating in bingo in the activity room. LPA interviewed 6 staff and 7 residents. LPA reviewed 6 staff files. All staff files reviewed had the required training. No discrepancies observed in the staff files. LPA reviewed 7 resident records and medications, no discrepancies were observed. The last fire drill was conducted on May 13, 2024. LPA consulted with the Executive Director regarding reporting requirements. No deficiencies are being cited as a result of this visit. An exit interview was conducted with Executive Director and a copy of the report provided. LPA consulted with the Executive Director regarding reporting requirements. No deficiencies are being cited as a result of this visit. An exit interview was conducted with Executive Director and a copy of the report providedthe state’s words, verbatim · CDSS document, May 29, 2024

Allegation investigated: Facility failed to provide resident's records to authorized representative.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director (ED) Sabrina Priesman and explained the reason for the visit. LPA and ED Priesman toured the facility. The investigation into the allegation, facility failed to provide resident's records to authorized representative revealed the following. The ED reported that Resident 1 (R1) has never lived at the facility. A review of facility records shows R1 was never a resident at the facility. The ED reported that no request was received regarding the request of records for R1. Based on the evidence gathered the allegation, facility failed to provide resident's records to authorized representative is deemed unfounded, meaning the allegation is false could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided. Unfoundedthe state’s words, verbatim · CDSS document, Dec 4, 2023 · control 22-AS-20231129103032

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.