Atria Carmichael Oaks

On 05/20/2026, Licensing Program Analyst (LPA) Graham Gunby arrived at the facility unannounced to deliver complaint findings into the allegation listed above and met with Executive Director, Kayla Davis. The department conducted record review, observations, and interviews with staff to investigate this allegation. During the interview with S1 it was revealed that R1 currently lives in their Independent Living. R1 does not receive any assistance from the facility. During the interview process it was reported that staff check on independent residents once a day and as needed. Staff are aware of resident needs for adequate care and supervision per their needs and service plans. Interviews did not indicate any concern in proper care and supervision for residents by staff in the common areas of the facility. Dining room and kitchen are thoroughly monitored by staff to prevent residents from entering unrestricted areas. Based on this information, these allegations are UNSUBSTANTIATED. AlthoRead the full finding— CDSS inspection report, May 20, 2026 · control 59-AS-20251230131934

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint investigation findings. LPA met with Kayla Davis during today’s investigation. LPA investigated allegation, “Staff did not ensure that resident's dietary needs were met.” LPA interviewed relevant parties and staff and reviewed resident medical documentation and facility documentation. Relevant party stated facility staff were not feeding R1 properly or regularly once R1 began to decline on hospice care. LPA interviewed administrator in which she stated R1’s diet changed to puree, and administrator was getting it approved, and the food supplies ordered when R1 moved out. LPA interviewed hospice staff in which they stated the facility never stopped feeding R1 but due to their policies they were unable to physically feed R1 and were unable to meet their needs. Hospice recommended R1 to move to a higher level of care. LPA reviewed hospice documentation in which it stated R1’s food intake was decliningRead the full finding— CDSS inspection report, February 25, 2026 · control 59-AS-20251021095832

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Kayla Davis, to deliver complaint investigation findings regarding the above stated allegation. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. According to resident (R1’s) Physician’s Report LIC602A, dated January 31, 2024, they were diagnosed with a primary diagnosis of Dementia. Unusual Incident/Injury Report LIC624, dated January 24, 2025, indicated that, on January 23, 2025, R1 was wandering the hallways and opening other residents’ doors. R1 appeared confused and not at their baseline. R1 was transported to the hospital. R1’s Resident Notes, dated January 23, 2025, indicated that facility staff were notified by a resident that R1 had opened another resident’s door, waking them. Resident Notes indicated that staff responded and found R1 confused and not at baseline, so R1 was transported to the hRead the full finding— CDSS inspection report, September 3, 2025 · control 59-AS-20250204095142

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director (ED), Kayla Davis, to open complaint and deliver findings into the complaint allegations listed above. During today's visit, LPA was informed by the ED that resident (R1) has never resided at the facility. ED contacted the ED, Kimberly Hagen, at the Atria El Camino Gardens location. LPA was informed that R1 moved out of the El Camino Gardens location on 8/11/2023. Allegation: Staff did not disclose previous complaints filed. The complaint is regarding not being notified of complaints filed at the Atria locations in Walnut Creek and San Mateo. The facility is only required to disclose complaints filed at their location. *********************************************Continued on LIC9099-C**************************************************** UnfoundedRead the full finding— CDSS inspection report, September 7, 2023 · control 59-AS-20230901100431

On 7/11/23, Licensing Program Analyst (LPA) Kevin Mknelly spoke to Christina Ortiz, Assistant Executive Director, to deliver complaint findings for the above allegation. LPA also spoke with Kimberly Hagen, Executive Director by phone. LPA reviewed resident records, facility records and conducted extensive interviews. LPA finds that the allegations cited above are substantiated. In April 2023, R1 was admitted to the facility with an LIC 602- Physician’s Report diagnosis of dementia. At the time of admission, R1 presented with assistance needs where it was determined that placement in the memory care wing appeared most appropriate. At that time, R1 and their responsible party agreed to the placement. On 5/25/23, R1 was seen by a physician who changed the diagnosis from dementia to R1 having had delirium that was now resolved. By 5/25/23, R1 was voicing their desire, to family and facility staff, to no longer live in the memory care wing and wished to move to assisted living. SubstantiateRead the full finding— CDSS inspection report, July 11, 2023 · control 59-AS-20230531123647

On 7/11/23, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Christina Ortiz. LPA conducted records review and interviews. LPA is unable to find and or meet the preponderance, per policy. The investigation found that R1 has reported items missing, witnesses nor suspects were identified. R1 denies that the reported missing items have been recovered. During the time that items were reported to have been missing, facility door records showed the resident's door to have been unlocked when R1 was not present. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with Christina Ortiz. Copy of this report provided UnsubstantiatedRead the full finding— CDSS inspection report, July 11, 2023 · control 59-AS-20230525110934

to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following— CDSS inspection report, June 28, 2023