Atria Golden Creek

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility did not prevent resident falls due to lack of staffing

On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and Kimberly Lyman conducted an uannounced visit to deliver complaint findings. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. The Department received a complaint on 01/21/2026 and LPA Mendivil conducted the initial 10 day visit on 01/30/2026. During the course of the investigation LPAs interivewed staff and residents and obtained copies of resident records including service plan and physician's reports. Regarding the allegation faciltiy did not prevent resident falls due to lack of staff the investigaiton revealed the following: Per interview with Executive Director Jeremy Gilmore the current staffing levels for Memory Care is as follows: for AM 5 staff including 4 caregivers and 1 med-tech, PM 5 staff including 4 caregivers + 1 med-tech, and NOC 3 staff including 2 caregiver and 1 med-tech. Per interviews with 5 out of 5 staff stated they are able to meet residents nthe state’s words, verbatim · CDSS document, Apr 14, 2026 · control 22-AS-20260121131042

Allegation investigated: Uncleared staff providing care to residents

On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and Kimberly Lyman made an unannounced visit to conduct a compaint investigation. LPAs were greeted and granted entry into the faciltiy by staff and explained the reason for the visit. The Department received a complaint on 04/13/2026. During the course of the visit LPAs obtained copies of staff roster and reviewed a random selection of 6 staf members records. Regarding the allegation uncleared staff providing care to residents the investigation revealed the following: It was alleged that uncleared staff were providing care to residents, per review of staff criminal records clearance and staff roster all staff have obtained a criminal record clearance and are associated to the faciltiy. Therefore based on the preponderance of evidence through records reviewed the allegation uncleared staff are providing care to residents is determined to be UNFOUNDED, meaning that the allegation is false, could not have happened and/or is wthe state’s words, verbatim · CDSS document, Apr 14, 2026 · control 22-AS-20260413161414

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff mismanaging resident’s medications. Staff mismanaging residents medical records. Staff not administering medications to residents according to physician’s orders. Centrally stored medications are not kept in a safe and locked place. Staff failed to report observed changes of condition. Staff failed to report incident(s). Residents have scabies. Staff failed to protect residents from harm.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above for the purpose of delivering findings. LPA met with Executive Director (ED) Jeremy Gilmore. Regarding allegations, Staff mismanaging resident’s medications, Staff mismanaging residents’ medical records, and Staff not administering medications to residents according to physician’s orders, the following was revealed: it is alleged staff forged physician signatures, altered physician orders, postponed the construction of resident binders leaving incomplete paperwork, and delayed the destruction of narcotics. During the course of the investigation, LPA conducted a tour of the facility, including the medication room, and conducted file review for select residents. LPA observed medication to be centrally stored and locked in medication carts located within the medication room. LPA observed narcotics for select residents to be currentthe state’s words, verbatim · CDSS document, Feb 6, 2026 · control 22-AS-20210226151742

Allegation investigated: Facility lacks staffing in which resident needs are not being met.

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit. The Department received a complaint on 08/27/2025 and LPA Mendivil conducted the initial 10 day visit 09/04/2025. LPA interviewed staff and residents and obtained copies of caregiver schedule for September/October 2025, admission agreement, cleaning/laundry schedule. Regarding the allegation facility lacks staffing in which resident needs are not be met the investigation revealed the following: It was alleged there is not enough staff to meet residents needs. Based on interviews with staff and Executive Director Jeremy Gilmore, there are about 35-40 residents that have care plans with varying levels of assistance needed in Assisted Living. Executive Director Jeremy stated there are 3 caregivers and 1 med-tech scheduled for AM shift and PM shift in Assisted Living and 2 caregiversthe state’s words, verbatim · CDSS document, Oct 23, 2025 · control 22-AS-20250827083931

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident sustained an injury from a fall while in care

This is an amended report. This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by Receptionist Maria McKennett. LPA met with Executive Director, Dorice Redman (ED) and explained the nature of the inspection. The department received a complaint on 12/15/2020 alleging a resident sustained an injury from a fall while in care. The Reporting Party (RP) disclosed that a resident was hospitalized for major blunt trauma due to an unwitnessed fall. During the investigation, the department interviewed Executive Director, staff and residents. (continued on LIC9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 26, 2024 · control 22-AS-20201215112452

Allegation investigated: Illegal eviction

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility by Executive Director Dori Redman and explained the reason for the visit. During the course of the investigation LPA toured the facility, interviewed Executive Director and resident as well as reviewed and obtained pertinent documentation such as facility notes. Regarding the allegation of Illegal eviction, the investigation revealed the following: Facility served a thirty day notice to Resident 1 (R1) on March 7, 2024 for violation of house rules regarding alcohol abuse. House rules verbiage indicates "abuse of alcohol will not be tolerated." LPA reviewed six incident reports outlining public intoxication and subsequent hospitalization from the episodes with the last one being March 6, 2024. Interview with R1 confirms episodes of intoxication. Facility documented ten instances of public intoxthe state’s words, verbatim · CDSS document, Mar 15, 2024 · control 22-AS-20240308100024

Allegation investigated: Resident sustained multiple pressure injuries due to neglect

Licensing Program Analyst (LPA) Lydia Martinez conducted and unannounced visit to the facility to deliver findings on the above allegation. LPA identified herself and discussed the purpose of the visit with Administrator (AD) James Craddock. The complaint was investigated by the Department. During the investigation, interviews were conducted with facility Administrator, staff and witnesses. Additionally, copies of Resident 1 (R1) records, Incident Report (LIC624), Kaiser Permanente Medical Records, and Apex Hospice Records were obtained and reviewed. R1 was a resident of Atria Golden Creek since 8/30/2020. R1 was in the hospital on 11/29/2020 for altered level of consciousness due to UTI/sepsis and was discharged back to Atria on 12/04/2020. R1 was receiving hospice services from Apex Hospice Care, Inc. and was being seen by a nurse and health aide two times per week. R1 was in the hospital again on 12/17/2020 and multiple pressure injuries were found during R1’s admission into the hosthe state’s words, verbatim · CDSS document, Aug 30, 2023 · control 22-AS-20201218140845