Atria Covina

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vaid conducted an unannounced annual inspection visit. LPA met with Administrator Crystene Char and the purpose of today's visit was discussed. The facility has a capacity of 90 residents and is licensed to serve elderly residents age 60 and above. The facility is approved for fifty-six (56) non-ambulatory residents. The facility has ten (10) hospice waivers on file. Administrator certificate is current and expires on 12/20/2026. The annual inspection consisted of; conducting physical plant; reviewing food supply, staff and residents’ files, and medication; and interviewing of staff/residents. 1.Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. 2.Disaster Preparedness: The facility has the Emergency Disaster Plan in place. The emergency disaster drills include fire, elopement, and stairwell evacuation, conducted every quarter. Last emergency drill was on 04/28/2026 Disaster training is conducted by the corporate office every quarter. 3.Resident Rights-Information: Resident rights are included in Resident files. The let-us-no and ombudsman posters were observed to be posted in the hallway near the reception desk. 4.Planned Activities: Activity schedule/calendar is posted inside the activity room. There is an activity coordinator and activity assistant for this facility on weekly basis. CONTINUED ON 809C............... 5.Physical Plant & Environment Safety: LPAs toured facility grounds. The facility is a two-story building with 63 resident rooms. The facility consists of seven (7) office rooms, reception area, medication room, library, activity room, dining room, kitchen, two (2) laundry rooms, two (2) housekeeping storage rooms, staff lounge, and courtyard. Four (4) public restrooms are available which are clean and operational. Smoke alarms and carbon monoxide detectors were observed and are operable. Fire extinguishers are located throughout the premises (service date of 12/10/2025) Water temperature measured in eight (8) residents’ bathrooms is within 105–120-degree F. Bathrooms had non-skid surfaces and grab bars. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. 6.Operational Requirements: The fire clearance is approved has a capacity of 90 residents and licensed to serve elderly residents age 60 and above. The facility is approved for fifty-six (56) non-ambulatory residents. The facility has ten (10) hospice waivers on file, five (5) residents are on hospice, and eight (8) residents with dementia. Administrator certificate is current and expires on 12/20/2026. Staff are adhering to operational requirements. 7.Food Service: Dining area has adequate seating. Plates, cups and utensils are kept clean and stored properly. Kitchen is kept clean and free from rodents and other vermin. There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator and freezer. Pesticides and cleaning supplies are kept away from the food preparation areas. Weekly menu is posted in hallway next to dining hall. Special diets are served, low sodium, low/no sugar. Residents can request special meals. 8.Staffing: Facility has reasonable staffing; staff were observed assisting residents with their activities. 9.Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Staff #1 through Staff #5. Staff have their Health and TB Screening on file. Association and clearance. First Aid and CPR certificates on file. 10.Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 through Resident #6. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Functional Capabilities, ALW assessment and Resident Rights were observed. 11.Incidental M&D: The medications are centrally stored in the medication room and in bubble packs and/or original containers. Medications are administered as prescribed by the Physician and marked in the Medicine Administered Record (MARs). 12.Residents with SHN: Facility does not use manual restraints at this facility. No deficiencies were noted on today's visit. An exit interview was conducted with Administrator Crystene Char and copy of LIC 809s were provided.the state’s words, verbatim · CDSS document, Aug 11, 2026

Allegation investigated: Staff did not dispense medications to resident as prescribed. Staff did not provide resident’s representative with requested records in a timely manner. Licensee charged resident for services not received.

***This report supersedes the report delivered on 01/16/2026. The findings will remain unsubstantiated. *** On 01/16/26, Licensing Program Analyst (LPA) Vaid conducted a subsequential visit to deliver the findings for the above-mentioned allegations. Met with Crystene Char, toured the facility and did not observe any health and safety concerns. On 12/12/25, Licensing Program Analyst (LPA) Vaid conducted a subsequential visit to deliver the findings for the above-mentioned allegations. Met with Crystene Char, toured the facility and did not observe any health and safety concerns. On 5/6/25, Licensing Program Analyst (LPA) S Vaid conducted an initial 10-day complaint investigation visit for the above allegations. LPA met with Irina Sarkisyan, Community Business Director, Crystene Char, Administrator was notified, Administrator arrived shortly after, and complaint was discussed. LPA Vaid and Administrator Char did not observe any safety concerns during the facility tour. CONTINUED ON 9099C…………………. Unsubstantiated ***This report supersedes the report delivered on 01/16/2026. The findings will remain unsubstantiated. *** The investigation consisted of the following: LPA toured the physical plant. LPA Interviewed staff 1-7 (S1-S7), and residents #2-#8 (R2-R8) resident R1 is currently in skilled nursing home. LPA requested, collected, and reviewed documents from R1's face sheet, physicians reports, admissions agreement, preplacement Assessment, medication log MARs, list of residents’ medications, plan of care and service plan and copies of four (4) random residents: face sheet, physician reports, admissions agreement, preplacement assessments, and medication list. Telephone contact information about staff and residents. Staff and residents’ rosters. The investigation revealed the following: Regarding the allegation: Staff did not dispense medications to resident as prescribed. It is alleged that the staff did not dispense and administer medications to resident#1(R1) as prescribed. Seven (7) of seven (7) staff interviewed denied this allegation. Staff interviewed stated they dispensed and administered R1’s medication as listed on the prescribed physicians’ orders received. The medications not transferred from R1’s previous pharmacy were communicated to R1’s physician on 04/01/25 and the facility pharmacy was awaiting insurance approval for the medication. Staff stated they communicated the medication and pharmacy issue to R1 and their POA’s to help resolve. Seven (7) of eight (8) residents interviewed could not corroborate this. According to the records reviewed medication list received dated 4/01/25 listed fourteen (14) medications, Nine (9) medications with four (4) PRN’s and one (1) medication on hold. According to records reviewed R1’s pharmacy had already provided R1’s family with the month’s medication allowance. Facility requested R1 and family bring the medication to the facility. Facility made multiple attempts to notify R1’s physician(s) and requested medication reconciliation, no response was received. R1 moved to the facility on 04/01/25 and was admitted to the hospital on 4/15/25. Records show R1 was administered medications dosage correctly from the MARs log dated 04/01/25 to 04/15/25, staff dispensed and R1 was administered their medication as prescribed. Based on LPAs records reviewed and interviews which were conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. CONTINUED ON 9099C........... ***This report supersedes the report delivered on 01/16/2026. The findings will remain unsubstantiated. *** Regarding the allegation: Staff did not provide resident’s representative with requested records in a timely manner. It is alleged that the staff did not provide resident #1(R1) representatives with requested medication records in a timely manner. Seven (7) of seven (7) staff interviewed denied the allegation. Seven (7) of eight (8) residents could not corroborate this allegation. According to staff interviewed, records request is handled by the resident service director and administrator. R1’s POA request for records was communicated to the administrator and request for medication records was provided to R1’s POA within five (5) days. Request for records was made on 4/18/25 and records were provided to R1’s POA on 4/23/25 by the staff at Atria. Based on LPAs records reviewed and interviews which were conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Licensee charged resident for services not received. It is alleged that the Licensee has charged Resident #1(R1) for services not received. Resident #1 being overcharged with the room rental rate, only having lived in the community for two weeks. Seven (7) of seven (7) staff interviewed denied this allegation. Seven (7) of eight (8) residents could not corroborate this allegation. According to record review, R1 signed and dated the admissions agreement and is therefore held responsible for rental payment until the end of April. Thirty (30)day notice to leave the community was sent the administrator on 4/18/25, R1 is responsible for the payment of the room rental until 05/18/25, as agreed in the admissions agreement dated 03/31/2025 by R1. Based on LPAs records reviewed and interviews which were conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and copy of these licensing report was provided to Administrator Crystene Char.the state’s words, verbatim · CDSS document, Feb 9, 2026 · control 28-AS-20250501163701

Allegation investigated: Staff did not dispense medications to resident as prescribed. Staff did not provide resident’s representative with requested records in a timely manner. Licensee charged resident for services not received.

Licensing Program Analyst (LPA) Vaid conducted a subsequential visit to deliver the findings for the above-mentioned allegations. Met with Crystene Char, toured the facility and did not observe any health and safety concerns. On 5/6/25, Licensing Program Analyst (LPA) S Vaid conducted an initial 10-day complaint investigation visit for the above allegations. LPA met with Irina Sarkisyan, Community Business Director, Crystene Char, Administrator was notified, Administrator arrived shortly after, and complaint was discussed. LPA Vaid and Administrator Char did not observe any safety concerns during the facility tour. The investigation consisted of the following: LPA toured the physical plant. LPA Interviewed staff 1-7 (S1-S7), and residents #2-#8 (R2-R8) resident R1 is currently in skilled nursing home. LPA requested, collected, and reviewed documents from R1's face sheet, physicians reports, admissions agreement, preplacement Assessment, medication log MARs, list of residents’ medications, plan of care and service plan and copies of four (4) random residents: face sheet, physician reports, admissions agreement, preplacement assessments, and medication list. Telephone contact information about staff and residents. Staff and residents’ rosters. CONTINUED ON 9099C…………………. Unsubstantiated The investigation revealed the following: Regarding the allegation: Staff did not dispense medications to resident as prescribed. It is alleged that the staff did not dispense and administer medications to resident# 1(R1) as prescribed. Seven (7) of seven (7) staff interviewed denied this allegation. Staff interviewed stated they dispensed and administered R1’s medication as listed on the prescribed physicians’ orders received. Four (4) medications were not transferred to the facilities’ pharmacy from R1’s previous pharmacy and therefore were not administered. Staff stated they communicated the medications and pharmacy issue to R1 and their POA’s. Seven (7) of eight (8) residents interviewed could not corroborate this. According to the records reviewed medication list dated 4/01/25 listed fifteen (15) medications, four medications are shown as not administered. R1 moved to the facility on 04/01/25 and was admitted to the hospital on 4/15/25. Records show R1 was administered medications dosage correctly. The medical report dated 4/16/25, indicated R1’s attending physician suspected R1 did not receive medications at assisted living due to issues with the pharmacy. Staff dispensed all the prescribed medications transferred from R1’s previous pharmacy and awaiting approval from R1’s insurance to approval of the remaining. Medications log indicates all medications were prescribed were dispensed and administered to R1. Based on LPAs records reviewed and interviews which were conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Staff did not provide resident’s representative with requested records in a timely manner. It is alleged that the staff did not provide resident #1(R1) representatives with requested medication records in a timely manner. Seven (7) of seven (7) staff interviewed denied the allegation. Seven (7) of eight (8) residents could not corroborate this allegation. According to staff interviewed, records request is handled by the resident service director and administrator. R1’s POA request for records was communicated to the administrator and request for medication records was provided to R1’s POA within five (5) days. Request for records was made on 4/18/25 and records were provided to R1’s POA on 4/23/25 by the staff at Atria. Based on LPAs records reviewed and interviews which were conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. CONTINUED 9099C……….. Regarding the allegation: Licensee charged resident for services not received. It is alleged that the Licensee has charged Resident #1(R1) for services not received. Resident #1 being overcharged with the room rental rate, only having lived in the community for two weeks. Seven (7) of seven (7) staff interviewed denied this allegation. Seven (7) of eight (8) residents could not corroborate this allegation. According to record review, R1 signed and dated the admissions agreement and is therefore held responsible for rental payment until the end of April. Thirty (30)day notice to leave the community was sent the administrator on 4/18/25, R1 is responsible for the payment of the room rental until 05/18/25, as agreed in the admissions agreement dated 03/31/2025 by R1. Based on LPAs records reviewed and interviews which were conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Copy of this report was provided to Administrator Crystene Char.the state’s words, verbatim · CDSS document, Jan 16, 2026 · control 28-AS-20250501163701

Allegation investigated: Staff did not dispense medications to resident as prescribed. Staff did not provide resident’s representative with requested records in a timely manner. Licensee charged resident for services not received.

****The reason for the amendment is to remove confidential information listed on the initial report dated 12/12/25. The findings will remain unsubstantiated. ** Licensing Program Analyst (LPA) Vaid conducted a subsequential visit to deliver the findings for the above-mentioned allegations. Met with Crystene Char, toured the facility and did not observe any health and safety concerns. On 05/06/25, Licensing Program Analyst (LPA) S Vaid conducted an initial 10-day complaint investigation visit for the above allegations. LPA met with Irina Sarkisyan, Community Business Director, Crystene Char, Administrator was notified, Administrator arrived shortly after, and complaint was discussed. LPA Vaid and Administrator Char did not observe any safety concerns during the facility tour. The investigation consisted of the following: LPA toured the physical plant. LPA Interviewed staff 1-7 (S1-S7), and residents #2-#8 (R2-R8) resident R1 is currently in skilled nursing home. LPA requested, collected, and reviewed documents from R1's face sheet, physicians reports, admissions agreement, preplacement Assessment, medication log MARs, list of residents’ medications, plan of care and service plan and copies of four (4) random residents: face sheet, physician reports, admissions agreement, preplacement assessments, and medication list. Telephone contact information about staff and residents. Staff and residents’ rosters. CONTINUED ON 9099C…………………. Unsubstantiated The investigation revealed the following: Regarding the allegation: Staff did not dispense medications to resident as prescribed. It is alleged that the staff did not dispense and administer medications to resident#1 (R1) as prescribed. Seven (7) of seven (7) staff interviewed denied this allegation. Staff interviewed stated they dispensed and administered R1’s medication as listed on the prescribed physicians’ orders received. The medications not transferred from R1’s previous pharmacy were communicated to R1’s physician on 04/01/25 and the facility pharmacy was awaiting insurance approval for the medication. Staff stated they communicated the medication and pharmacy issue to R1 and their POA’s to help resolve. Seven (7) of eight (8) residents interviewed could not corroborate this. According to the records reviewed medication list received dated 4/01/25 listed fourteen (14) medications, Nine (9) medications with four (4) PRN’s and one (1) medication on hold. Staff awaited approval from R1’s insurance for the remainder. R1 moved to the facility on 04/01/25 and was admitted to the hospital on 4/15/25. Records show R1 was administered medications dosage correctly from the MARs log dated 04/01/25 to 04/15/25, staff dispensed and R1 was administered their medication as prescribed. Based on LPAs records reviewed and interviews which were conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Staff did not provide resident’s representative with requested records in a timely manner. It is alleged that the staff did not provide resident #1(R1) representatives with requested medication records in a timely manner. Seven (7) of seven (7) staff interviewed denied the allegation. Seven (7) of eight (8) residents could not corroborate this allegation. According to staff interviewed, records request is handled by the resident service director and administrator. R1’s POA request for records was communicated to the administrator and request for medication records was provided to R1’s POA within five (5) days. Request for records was made on 4/18/25 and records were provided to R1’s POA on 4/23/25 by the staff at Atria. Based on LPAs records reviewed and interviews which were conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. CONTINUED 9099C……….. Regarding the allegation: Licensee charged resident for services not received. It is alleged that the Licensee has charged Resident #1(R1) for services not received. Resident #1 being overcharged with the room rental rate, only having lived in the community for two weeks. Seven (7) of seven (7) staff interviewed denied this allegation. Seven (7) of eight (8) residents could not corroborate this allegation. According to record review, R1 signed and dated the admissions agreement and is therefore held responsible for rental payment until the end of April. Thirty (30)day notice to leave the community was sent the administrator on 4/18/25, R1 is responsible for the payment of the room rental until 05/18/25, as agreed in the admissions agreement dated 03/31/2025 by R1. Based on LPAs records reviewed and interviews which were conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Copy of this report was provided to Administrator Crystene Char.the state’s words, verbatim · CDSS document, Jan 16, 2026 · control 28-AS-20250501163701

Allegation investigated: Staff did not dispense medications to resident as prescribed. Staff did not provide resident’s representative with requested records in a timely manner. Licensee charged resident for services not received.

***This report supersedes the report delivered on 12/19/2025. The findings will remain unsubstantiated. *** On 12/12/25, Licensing Program Analyst (LPA) Vaid conducted a subsequential visit to deliver the findings for the above-mentioned allegations. Met with Crystene Char, toured the facility and did not observe any health and safety concerns. On 5/6/25, Licensing Program Analyst (LPA) S Vaid conducted an initial 10-day complaint investigation visit for the above allegations. LPA met with Irina Sarkisyan, Community Business Director, Crystene Char, Administrator was notified, Administrator arrived shortly after, and complaint was discussed. LPA Vaid and Administrator Char did not observe any safety concerns during the facility tour. The investigation consisted of the following: LPA toured the physical plant. LPA Interviewed staff 1-7 (S1-S7), and residents #2-#8 (R2-R8) resident R1 is currently in skilled nursing home. LPA requested, collected, and reviewed documents from R1's face sheet, physicians reports, admissions agreement, preplacement Assessment, medication log MARs, list of residents’ medications, plan of care and service plan and copies of four (4) random residents: face sheet, physician reports, admissions agreement, preplacement assessments, and medication list. Telephone contact information about staff and residents. Staff and residents’ rosters. CONTINUED ON 9099C…………………. Unsubstantiated ***This report supersedes the report delivered on 12/19/2025. The findings will remain unsubstantiated. *** The investigation revealed the following: Regarding the allegation: Staff did not dispense medications to resident as prescribed. It is alleged that the staff did not dispense and administer medications to resident#1(R1) as prescribed. Seven (7) of seven (7) staff interviewed denied this allegation. Staff interviewed stated they dispensed and administered R1’s medication as listed on the prescribed physicians’ orders received. The medications not transferred from R1’s previous pharmacy were communicated to R1’s physician on 04/01/25 and the facility pharmacy was awaiting insurance approval for the medication. Staff stated they communicated the medication and pharmacy issue to R1 and their POA’s to help resolve. Seven (7) of eight (8) residents interviewed could not corroborate this. According to the records reviewed medication list received dated 4/01/25 listed fourteen (14) medications, Nine (9) medications with four (4) PRN’s and one (1) medication on hold. According to records reviewed R1’s pharmacy had already provided R1’s family with the month’s medication allowance. Facility requested R1 and family bring the medication to the facility. Facility made multiple attempts to notify R1’s physician(s) and requested medication reconciliation, no response was received. R1 moved to the facility on 04/01/25 and was admitted to the hospital on 4/15/25. Records show R1 was administered medications dosage correctly from the MARs log dated 04/01/25 to 04/15/25, staff dispensed and R1 was administered their medication as prescribed. Based on LPAs records reviewed and interviews which were conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Staff did not provide resident’s representative with requested records in a timely manner. It is alleged that the staff did not provide resident #1(R1) representatives with requested medication records in a timely manner. Seven (7) of seven (7) staff interviewed denied the allegation. Seven (7) of eight (8) residents could not corroborate this allegation. According to staff interviewed, records request is handled by the resident service director and administrator. R1’s POA request for records was communicated to the administrator and request for medication records was provided to R1’s POA within five (5) days. Request for records was made on 4/18/25 and records were provided to R1’s POA on 4/23/25 by the staff at Atria. Based on LPAs records reviewed and interviews which were conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. CONTINUED 9099C……….. ***This report supersedes the report delivered on 12/19/2025. The findings will remain unsubstantiated. *** Regarding the allegation: Licensee charged resident for services not received. It is alleged that the Licensee has charged Resident #1(R1) for services not received. Resident #1 being overcharged with the room rental rate, only having lived in the community for two weeks. Seven (7) of seven (7) staff interviewed denied this allegation. Seven (7) of eight (8) residents could not corroborate this allegation. According to record review, R1 signed and dated the admissions agreement and is therefore held responsible for rental payment until the end of April. Thirty (30)day notice to leave the community was sent the administrator on 4/18/25, R1 is responsible for the payment of the room rental until 05/18/25, as agreed in the admissions agreement dated 03/31/2025 by R1. Based on LPAs records reviewed and interviews which were conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Copy of this report was provided to Administrator Crystene Char.the state’s words, verbatim · CDSS document, Jan 16, 2026 · control 28-AS-20250501163701

Allegation investigated: Staff did not dispense medications to resident as prescribed. Staff did not provide resident’s representative with requested records in a timely manner. Licensee charged resident for services not received.

***This report supersedes the report delivered on 12/12/2025. The reason for the amendment is to remove confidential information listed on the initial report. The findings will remain unsubstantiated. *** Licensing Program Analyst (LPA) Vaid conducted a subsequential visit to deliver the findings for the above-mentioned allegations. Met with Crystene Char, toured the facility and did not observe any health and safety concerns. On 5/6/25, Licensing Program Analyst (LPA) S Vaid conducted an initial 10-day complaint investigation visit for the above allegations. LPA met with Irina Sarkisyan, Community Business Director, Crystene Char, Administrator was notified, Administrator arrived shortly after, and complaint was discussed. LPA Vaid and Administrator Char did not observe any safety concerns during the facility tour. The investigation consisted of the following: LPA toured the physical plant. LPA Interviewed staff 1-7 (S1-S7), and residents #2-#8 (R2-R8) resident R1 is currently in skilled nursing home. LPA requested, collected, and reviewed documents from R1's face sheet, physicians reports, admissions agreement, preplacement Assessment, medication log MARs, list of residents’ medications, plan of care and service plan and copies of four (4) random residents: face sheet, physician reports, admissions agreement, preplacement assessments, and medication list. Telephone contact information about staff and residents. Staff and residents’ rosters. CONTINUED ON 9099C…………………. Unsubstantiated ***This report supersedes the report delivered on 12/12/2025. The reason for the amendment is to remove confidential information listed on the initial report. The findings will remain unsubstantiated. *** The investigation revealed the following: Regarding the allegation: Staff did not dispense medications to resident as prescribed. It is alleged that the staff did not dispense and administer medications to resident# 1(R1) as prescribed. Seven (7) of seven (7) staff interviewed denied this allegation. Staff interviewed stated they dispensed and administered R1’s medication as listed on the prescribed physicians’ orders received. The medications not transferred from R1’s previous pharmacy were communicated to R1’s physician on 04/01/25 and the facility pharmacy was awaiting insurance approval for the medication. Staff stated they communicated the medication and pharmacy issue to R1 and their POA’s to help resolve. Seven (7) of eight (8) residents interviewed could not corroborate this. According to the records reviewed medication list received dated 4/01/25 listed fourteen (14) medications, Nine (9) medications with four (4) PRN’s and one (1) medication on hold. Staff awaited approval from R1’s insurance for the remainder. R1 moved to the facility on 04/01/25 and was admitted to the hospital on 4/15/25. Records show R1 was administered medications dosage correctly from the MARs log dated 04/01/25 to 04/15/25, staff dispensed and R1 was administered their medication as prescribed. Based on LPAs records reviewed and interviews which were conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Staff did not provide resident’s representative with requested records in a timely manner. It is alleged that the staff did not provide resident #1(R1) representatives with requested medication records in a timely manner. Seven (7) of seven (7) staff interviewed denied the allegation. Seven (7) of eight (8) residents could not corroborate this allegation. According to staff interviewed, records request is handled by the resident service director and administrator. R1’s POA request for records was communicated to the administrator and request for medication records was provided to R1’s POA within five (5) days. Request for records was made on 4/18/25 and records were provided to R1’s POA on 4/23/25 by the staff at Atria. Based on LPAs records reviewed and interviews which were conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. CONTINUED 9099C……….. ***This report supersedes the report delivered on 12/12/2025. The reason for the amendment is to remove confidential information listed on the initial report. The findings will remain unsubstantiated. *** Regarding the allegation: Licensee charged resident for services not received. It is alleged that the Licensee has charged Resident #1(R1) for services not received. Resident #1 being overcharged with the room rental rate, only having lived in the community for two weeks. Seven (7) of seven (7) staff interviewed denied this allegation. Seven (7) of eight (8) residents could not corroborate this allegation. According to record review, R1 signed and dated the admissions agreement and is therefore held responsible for rental payment until the end of April. Thirty (30)day notice to leave the community was sent the administrator on 4/18/25, R1 is responsible for the payment of the room rental until 05/18/25, as agreed in the admissions agreement dated 03/31/2025 by R1. Based on LPAs records reviewed and interviews which were conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Copy of this report was provided to Zugey Soto, Resident Services Directorthe state’s words, verbatim · CDSS document, Dec 12, 2025 · control 28-AS-20250501163701

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vaid conducted an unannounced annual inspection visit. LPA met with Administrator Crystene Char and the purpose of today's visit was discussed. The facility has a capacity of 90 residents and licensed to serve elderly residents age 60 and above. The facility is approved for fifty-six (56) non-ambulatory residents. The facility has eight (8) hospice waiver on file, eight (8) residents are on hospice, and four (4) residents with dementia. Administrator certificate is current and expiring on 12/20/2026. The annual inspection consisted of applying CARE tools; conducting physical plant; reviewing food supply, staff and residents’ files, and medication; and interviewing of staff/residents. The facility is a two-story building with 63 resident rooms. The facility consists of seven (7) office rooms, reception area, med room, library, activity room, dining room, kitchen, two (2) laundry rooms, two (2) housekeeping storage rooms, staff lounge, and courtyard. Four (4) public restrooms are available which are clean and operational. 1.Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. [ CONTINUED ON 809C .....] 2.Operational Requirements: The fire clearance is approved has a capacity of 90 residents and licensed to serve elderly residents age 60 and above. The facility is approved for fifty-six (56) non-ambulatory residents. The facility has eight (8) hospice waiver on file, eight (8) residents are on hospice, and four (4) residents with dementia. Staff are adhering to operational requirements. 3.Physical Plant & Environment Safety: LPAs toured facility grounds. Smoke alarms and carbon monoxide detectors were observed. Both, smoke alarms and carbon monoxide detectors are operable. Fire extinguishers are located throughout the premises (service date of 12/17/2024) Water temperature measured in eight (8) residents’ bathrooms is within 105-120 degree F. Bathrooms had non-skid surfaces and grab bars. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. 4.Staffing: Facility has reasonable staffing; staff was observed assisting residents with their activities. 5.Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for S-#1 through Staff #6. Staff have their Health and TB Screening on file. Association and clearance. 6.Resident Rights-Information: Resident rights are included in Resident files. The let-us-no and ombudsman posters were observed to be posted in the hallway near the reception desk. 7.Planned Activities: Activity schedule/calendar is posted inside the activity room. There is an activity coordinator and activity assistant for this facility on weekly basis. 8.Food Service: Dining area has adequate seating. Plates, cups and utensils are kept cleaned and stored properly. Kitchen is kept clean and free from rodents and other vermin. There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator and freezer. Pesticides and cleaning supplies are kept away from the food preparation areas. [ CONTINUED ON 809C.....] 9.Incidental M&D: The medications are centrally stored in the medication room and in bubble packs and/or original containers. Medications are administered as prescribed by the Physician and marked in the Medicine Administered Record(MARs). 10.Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 through Resident #7. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Functional Capabilities, ALW assessment and Resident Rights were observed. 11.Disaster Preparedness: The facility has the Emergency Disaster Plan in place. The emergency disaster drills include fire, elopement, stairwell evacuation, conducted every quarter. Last emergency drill was on 6/26/2025. Disaster training is conducted by the corporate office every quarter. 12.Residents with SHN: Facility does not use manual restraints at this facility. No deficiencies were noted on today's visit. An exit interview was conducted with Administrator Crystene Char and copy of LIC 809s were provided.the state’s words, verbatim · CDSS document, Aug 7, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tao conducted an unannounced Case Management- Incident visit in response to resident#1 (R1) Incident Report, dated 08/21/24. The facility has a capacity of 90 residents and licensed to serve elderly residents age 60 and above. The facility is approved for fifty-six (56) non-ambulatory residents. LPA explained the purpose of today's visit to Irina Sarkisyan, Community Business Director who assisted with this visit. During today's visit LPA toured the facility, interviewed Administrator, staff, resident#1 (R1) and reviewed R1's file. The incident report stated R1 reported that staff took R1 out to the courtyard at 7am for 10 mins. R1 was upset and stated staff hit R1. LPA interviewed Administrator/staff revealed that the facility investigated this incident and the finding was unfound. Per interview of R1, resident seem unable to recall the incident. Police came and found it unfound. Case#24-18510. LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats. LPA obtained copies of the following documents: · Staff / Resident roster · R1’s Identification/Emergency Contact Information (facesheet) · Unusual Incident Report · Physician Report · In-service training No deficiencies were observed and cited during this visit. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 30, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tao conducted an unannounced Case Management- Incident visit in response to resident’s Incident Report, dated 07/24/24. The facility has a capacity of 90 residents and licensed to serve elderly residents age 60 and above. The facility is approved for fifty-six (56) non-ambulatory residents. LPA met with and explained the purpose of today's visit to Brooke Lamotte, Resident Service Director who assisted with this visit. During today's visit LPA toured the facility, interviewed staff /resident and reviewed resident's file. The incident report stated resident said to the administrator that staff slapped resident’s hands and not allowed resident to use restroom on resident’s initial request. LPA interviewed staff, it revealed the facility had investigated this incident and Brooke called police when she aware of the incident. The Covina Police come to investigate, and the finding was unfound. Police report # 24-16416. Per resident interview, resident stated the suspected abuser staff had slapped resident’s hands multiple times and resident reported no injuries by felt sad about the incidents. Regardless, the administrator decided to let go the suspected abuser staff on 7/25/24. The facility provided the in-service training to facility staff on 8/4/24 regarding abuses and mandated reporter. LPA obtained copies of Staff /Resident roster; Resident’s Identification/Emergency Contact Information (facesheet), Needs and service plan; Unusual Incident Report; Physician Report; In-service training documents and Employee Corrective action plan (let go the staff). LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats. No deficiencies were observed and cited during this visit. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 8, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Brooke Lamotte, Resident Service Director and the purpose of today's visit was discussed. The facility has a capacity of 90 residents and licensed to serve elderly residents age 60 and above. The facility is approved for fifty-six (56) non-ambulatory residents. The facility has eight (8) hospice waiver on file, six (6) residents are on hospice, and five (5) residents with dementia. Annual fees are current. Administrator certificate is current and expiring on 8/14/25. This annual inspection consisted of applying CARE tools; conducting physical plant; reviewing food supply, staff and residents files, and medication; and interviewing of staff/residents. The facility is a two-story building with 63 resident rooms. The facility consists of seven (7) office rooms, reception area, beauty salon, med room, library, activity room, dining room, kitchen, two (2) laundry rooms, two (2) housekeeping storage rooms, staff lounge, and courtyard. Four (4) public restrooms are available which are clean and operational. Resident rooms consisted of a bedroom, bathroom and closet. Residents' rooms and bathrooms were inspected and in compliance. Hot water temperature was measured in a range from 106.7 to 120.0 degrees Fahrenheit which was within Title 22 Regulation guidelines. Sufficient supply of perishable and nonperishable foods were observed. (-continued on LIC 809 C-) Smoke detectors and carbon monoxide detectors in residents' rooms are operable. Smoke detectors in the common areas are hard wired and monitored by a fire alarm company which it's last service was on 6/12/24. The fire extinguishers were fully charged. Elevator at the facility is operable. All mandated documents and signages are posted in common areas. The outdoor activity area is free of visible hazards and debris. There is shaded patio and garden areas with ample seating. Medications are centrally stored and locked. Resident records inspected are current. Fire/ Emergency drill conducted on 7/7/24. LPA checked the signal systems in resident rooms and found system to be operable and staff responded to residents in a range from 7 to 10 minutes. No deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6. An exit interview was conducted. This report was discussed with Administrator and report LIC 809s were provided.the state’s words, verbatim · CDSS document, Aug 8, 2024

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Tao and Reyes conducted an unannounced Case Management- Incident visit in response to Client (C1’s) Incident Report, dated 04/26/24. The facility has a capacity of 90 residents and licensed to serve elderly residents age 60 and above. The facility is approved for fifty-six (56) non-ambulatory residents. LPAs explained the purpose of today's visit to Irina Sarkisyan, Community Business Director and administrator who assisted with this visit. During today's visit LPA toured the facility, interviewed Administrator, staff, resident#1 (R1) and reviewed R1's file. The incident report stated R1 said to the administrator that staff grabbed and twisted resident#1’s right arm. LPA interviewed Administrator/staff revealed that the facility investigated this incident and the finding was unfound. Per interview of R1, resident seem unable to recall the incident. Staff and hospice nurse were monitoring the resident. LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats. LPA obtained copies of the following documents: · Staff roster/Resident roster · R1’s Identification/Emergency Contact Information (facesheet)/ Hospice Document · Needs and service plan/Unusual Incident Report/In-service training · Admission Agreement Attachment C (Personal Rights) · Physician Report /Pre appraisal / Admission Agreement No deficiencies were observed and cited during this visit. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 10, 2024