Atria Carmichael Oaks

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Cassandra Mikkelson and Cheyenne Ratajczak arrived unannounced and met with Tommi Black to conduct an annual inspection utilizing the inspection tool. LPA conducted an inspection of the care facility to ensure compliance with Title 22 regulations. LPA observed resident rooms, common area bathrooms, dining areas, kitchen, common areas, and perimeter of care faciity. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. Care facility has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are operational in the care facility. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication rooms and found medications to be locked away and inaccessible to the residents. LPA reviewed ten (10) resident files, five (5) staff files and resident medications. Facility has a current copy of certificate of liability insurance and LPA requested a copy. As a result of this visit, no deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted with Administrator.the state’s words, verbatim · CDSS document, Jul 16, 2026

Allegation investigated: Staff does not provide adequate supervision to resident.

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. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated. No deficiencies are being cited during today's inspection. Exit interview conducted, email of report is provided to Executive Director. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 20, 2026 · control 59-AS-20251230131934

Allegation investigated: Staff did not ensure that resident's dietary needs were met Staff did not assist resident with obtaining medical care Staff did not assist resident with ambulating Staff did not communicate with responsible party regarding resident's care Staff are charging resident for care not rendered

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 declining but no documentation was observed showing concerns about facility staff not meeting R1’s dietary needs. Continuation on 9099-C. Unsubstantiated LPA interviewed care staff in which they stated R1’s appetite began to decline while on hospice care but R1 was still able to eat finger foods and staff continuously offered food. Due to the information gathered LPA finds allegation to be Unsubstantiated. LPA investigated allegation, “Staff did not assist resident with obtaining medical care”. LPA interviewed relevant parties and staff and reviewed resident medical documentation and facility documentation. LPA interviewed relevant party in which they stated R1 was on hospice care but R1 was declining rapidly due to an untreated Urinary Tract Infection(UTI). Relevant Party stated once R1 was moved, new care staff observed signs of an UTI and R1 was treated and began to regain their strength. LPA interviewed care staff in which they stated they did not observe any signs of an UTI. Care staff stated they changed R1 every 2 hours or as needed. LPA interviewed hospice staff in which they stated they had no concerns with R1 receiving proper continence care. Hospice staff stated once R1 did move, new facility staff did report signs of a UTI and antibiotics were provided to R1 to resolve the issue. LPA reviewed hospice documentation, and found no concerns related to an UTI or continence care. LPA reviewed facility documentation, and found no concerns or documentation concerning continence care or an UTI. Due to the information gathered, LPA finds allegation to be Unsubstantiated. LPA investigated allegation, “Staff did not assist resident with ambulating”. LPA interviewed relevant parties and staff and reviewed resident medical documentation and facility documentation. LPA interviewed relevant party in which R1 began needing more caregiver assistance toward the end of their stay and staff would not help R1 out of bed and R1 became bedbound. Relevant party stated that once R1 moved out of the facility and received treatment for an UTI, R1 was no longer bedbound. LPA interviewed care staff in which they stated R1 was ambulatory and walking around facility until August 2025 while on hospice care. Continuation on 9099-C. R1’s health was declining and by September 2025 R1 was unsafe to ambulate independently and was bedbound. Caregiver stated they would try to get R1 out of bed but R1 was too weak to be moved into a wheelchair. R1 moved out of the facility on September 17th. LPA interviewed hospice staff in which they stated facility staff were assisting R1 with ambulating until September 2025 when R1 was needing more assistance to transfer and the facility had limitations with providing a lift assist. Hospice staff stated R1 needed a higher level of care and was moved shortly after. LPA reviewed facility documentation in which resident was ambulating in and out of bed until September 2nd, and a care conference was scheduled with responsible parties concerning R1’s decline. LPA reviewed hospice documentation, and there was no documentation showing facility staff were not assisting resident with ambulation. Due to the information gathered, LPA finds allegation to be unsubstantiated. LPA investigated allegation, “Staff did not communicate with responsible party regarding resident's care”. LPA interviewed relevant parties and staff and reviewed resident medical documentation and facility documentation. Relevant party stated facility staff would not communicate with R1’s responsible party regarding resident’s care and billing. LPA interviewed care staff and memory care manager in which they stated they spoke to R1’s responsible party several times a week and had a care conference with responsible party prior to R1’s move out. Memory care manager provided LPA emails and text messages to and from R1’s responsible party showing communication. LPA interviewed hospice staff in which they stated a care conference was held on 9/4/25 with facility staff, hospice, and responsible party over the phone concerning R1’s health concerns. Hospice staff stated they scheduled another in-person meeting with responsible party and no one from the facility showed up. Due to the information gathered LPA finds allegation to be Unsubstantiated. Continuation on 9099-C. LPA investigated allegation, "Staff are charging resident for care not rendered". LPA interviewed relevant parties and administrator and reviewed documentation. R1 was placed on hospice in June 2025 and their rates increased. Relevant party stated they were charged for services that were not rendered from facility staff and therefore the responsible party should be reimbursed for that. LPA interviewed administrator in which she stated once R1 moved out of the facility the responsible party requested for a refund. Normally facility requires a 30-day notice during the move out process but administrator stopped the fees on 9/17/25, the day R1 moved out. No further refund was issued. LPA interviewed staff in which they stated they provided proper care to R1. LPA interviewed hospice staff in which they stated there were no concerns about neglect but R1 needed to move out to higher level of care. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted and copy of report provided.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 59-AS-20251021095832

Allegation investigated: -Staff is not allowing resident to return to facility for re-entry.

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 hospital. **********************************************Continued on LIC9099-C********************************************** Substantiated Interviews with the Executive Director, Nurse, and Resident Services Coordinator indicated that R1 would be a good fit for the memory care unit at the care home. Hospital Records indicated that they spoke with facility staff on January 24, 2025 indicating that R1 could return to facility after lunch. Hospital was notified by facility on January 24, 2025 that R1 currently resides in assisted living and would be moved to memory care pending discussion with R1’s responsible party. Hospital completed an LIC602A for R1 to go back to the facility in memory care and faxed the form to the facility. R1’s Resident Notes, dated January 24, 2025, indicated that the facility spoke with R1’s responsible party and informed them about memory care placement for R1, and responsible party indicated ok. R1’s Residency Agreement, dated June 26, 2023, indicated that “If we determine that the level of care, we are providing you is not appropriate for your needs, we will implement a change in level of care and consult with you regarding the change. We will also inform your Responsible Person(s) of the need for an implementation of any such change”. Hospital Records indicated that, on January 25, 2025, the facility notified them that they will not be accepting R1 back. R1’s Resident Notes, dated January 25, 2025, indicated that they are not able to take R1 back due to safety issues and concerns. Staff interviews indicated that medical records stated R1 is a high risk of accidental self harm/self neglect if left unsupervised. However, medical records obtained indicated that there was no evidence of any self-harm, suicidal or homicidal ideation, plan or intent. Medical Records indicated that, on January 26, 2025, hospital staff spoke to R1’s responsible party who indicated that they would reach out to the facility to find out why they will not take R1 back as rent was paid until the end of the month. Medical Records indicated that R1’s responsible party assisted the hospital in finding placement for R1. Based on documentation reviewed and interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 59-AS-20250204095142

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Sep 17, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions... This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the facility did not accept resident (R1) back from the hospital, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Facility agrees to submit a statement of understanding of residents' rights to LPA by the POC due date of 9/17/2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced and met with the Executive Director, Kayla Davis, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed five (5) bedrooms in assisted living, one (1) bedroom in memory care, two (2) shower rooms, and common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 112.7 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kits are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed six (6) resident files and also reviewed six (6) staff files. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jul 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 6/11/24 and met with the Executive Director, Kayla Davis, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed four (4) bedrooms in assisted living, one (1) bedroom in memory care, two (2) shower rooms, and common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 109.2 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers and first aid kits are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed six (6) resident files and also reviewed six (6) staff files. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jun 11, 2024