Atria El Camino Gardens

Allegation investigated: -Staff do not ensure the residents have a safe, healthy, and comfortable environment -Staff do not treat residents with dignity and respect

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Dana Stansel, to deliver complaint investigation findings regarding the above stated allegations. During the course of the investigation, LPA conducted interviews, obtained documentation, and made observations. On August 7, 2026 and July 30, 2026, LPA toured all buildings of the facility (A, B, and C), which included memory care. LPA observed the facility to be clean, safe, sanitary and in good repair. On August 7, 2026, LPA observed all thermostats in main hallways of buildings A, B, and C to be set within the regulatory requirements. LPA also observed thermostats in nine (9) residents' rooms in memory care, which also were set within the regulatory temperature range. LPA observed the facility to be at a comfortable temperature. During the visit, LPA observed that building A, which included memory care, had new thermostats **********************************************Continued on LIC9099-C**************************************************** Unsubstantiated that were not reading the temperature accurately. Interview with the Maintenance Director indicated that they installed a new HVAC system in building A and would have the HVAC company check the system to ensure all systems are functioning properly. According to HVAC company invoice, dated August 10, 2026, the HVAC company inspected the new system and found that all systems were operating normally. The thermostats that were reading incorrectly were set to read in the attic by mistake upon install, so were adjusted to read the correct hallway they were installed. Interviews with residents (R1, R2, R3, and R4) indicated that the temperature is comfortable in the facility. R1, R2, R3, and R4 indicated that staff treat them well with dignity and respect. R1, R2, R3, and R4 indicated that they have no concerns regarding the facility's cleanliness, temperature, or the treatment from care staff. Based on interviews conducted, observations made, and documentation, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 25, 2026 · control 59-AS-20260731150312

Allegation investigated: -Staff do not provide fresh fruits or snacks to residents -Staff do not keep facility free from odor

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director (ED), Dana Stansel, to open and deliver complaint investigation findings regarding the above stated allegations. During today's visit, LPA toured the care home and conducted interviews. **********************************************Continued on LIC9099-C*************************************************** Unsubstantiated On July 30, 2026, LPA checked the kitchen area for the ability to prepare and store food. LPA observed fresh fruit, such as strawberries, grapes, bananas, and fruit salad already prepared. LPA observed kitchen staff preparing fresh cantaloupe. All produce appeared fresh. LPA observed The Grill Bistro to have grab and go snacks available to the residents. The Grill Bistro had fresh fruit, cheese, yogurt, apple sauce, eggs, prunes, cottage cheese, parfaits, drinks (water and soda), and sandwiches. The Grill Bistro had a back up supply of snack items in the small kitchen. Interview with staff (S1) indicated that snacks are served in memory care between meals. S1 stated that the morning snack is served around 10am and the afternoon snack is served around 2:30pm. The ED indicated that the evening snack is around 7pm. Interviews with residents (R1, R2, R3, and R4) indicated that the facility has fresh fruit and snacks available to residents. On July 30, 2026, LPA toured all buildings of the facility (A, B, and C), which included memory care. LPA did not observe any odors in the care home. The facility appeared to be clean and in good repair. Interviews with R1, R2, R3, and R4 indicated that they have never observed any odors in the care home. Based on interviews conducted and observations made, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided. On July 30, 2026, LPA toured all buildings of the care home (A, B, and C), which included memory care and did not observe any pests or bugs in the care home. LPA observed the coffee station in the lobby, the kitchen, The Grill Bistro, and the kitchen in memory care and did not observe any pests or bugs. Interviews with residents (R1 and R2) indicated that they have not seen bugs at the care home. Interview with resident (R3) indicated that there is no infestation of bugs at the facility. Interview with resident (R4) indicated that they had seen small pin sized bugs near The Grill Bistro, however, pest control came to provide services. Interview with ED indicated that ants were observed at the coffee station in the lobby, so pest control was contacted. ED indicated that the facility recently changed vendors for pest control services. The previous pest control services contract became effective on January 1, 2021, which included "proactive prevention: reliable protocols supported by science to help protect Customer through regular service visits using an outside-in approach" and "integrated methods: highly-trained and professional Service Specialists provide Customer with services that may include: inspection, pest monitoring, mechanical trapping, and biological and targeted product applications". The services provided are scheduled visits, as well as on-call services. According to invoices from the previous pest control service vendor, services were provided on twelve (12) occasions between April 16, 2026-June 27, 2026. The current pest control service contract became effective on July 9, 2026, which includes monthly proactive services as well as applying materials for pest eradication and prevention as needed. According to invoice, the pest control service initial visit was conducted on July 13, 2026, which included placing traps and bate stations. Invoices also indicated that pest control services were provided on July 20, 2026 and July 22, 2026. Services provided included rodent bait stations as well as treatment for ant activity. Based on documentation reviewed, interviews conducted, and observations made, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2026 · control 59-AS-20260728082157

Allegation investigated: -Facility unlawfully evicted resident.

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director (ED), Dana Stansel, 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) Medical Assessments LIC602A forms, dated November 25, 2025 and January 16, 2026, R1 did not require assistance with repositioning or transferring and was able to feed themselves. On January 27, 2026, R1 began receiving hospice services. R1's hospice care plan indicated that they would require supervised assistance with ambulation using a 4-wheeled walker and stand-by assist for a wheelchair. R1's LIC602A dated January 26, 2026 indicated that they required supervised assistance with repositioning and transferring and they were able to feed themselves. According to R1's care plan and *********************************************Continued on LIC9099-C************************************************** Unfounded assessment dated February 28, 2026, R1 required cue and one person assistance during transfers. R1's transfer ability required minimal assistance with daily supervision and cueing for transfers. R1 did not require any assistance during mealtime. Facility's internal notes indicated that, on March 9, 2026, R1 complained of pain and was advised by their hospice nurse to be transported to the hospital. R1's family transported them to the hospital where R1 was admitted. On March 18, 2026, the facility notated that R1 remained at the hospital due to a diagnosis of pneumonia. According to text message correspondence between the ED and R1's responsible party, dated March 21, 2026-March 22, 2026, R1's responsible party indicated that they would be moving R1 out of the care home. ED indicated that they would accept the text message as the 30-day notice for move out and agreed to a prorated rent amount for the month of April to the 19th. ED indicated that if the full amount is paid for April that the facility would refund for anytime after the 30-day notice. ED offered to calculate the April cost through the 19th if they wanted to pay that amount instead. Correspondence also indicated that R1's responsible party had spoken with facility staff regarding putting a stop to R1's Level 4 care and medication and laundry services as of March 21, 2026. ED indicated that they would figure it out based on the facility's guidelines. According to R1's Admission Agreement, signed on November 24, 2025, the facility calculated fees on a monthly basis. The Admission Agreement indicated that "fees are not adjusted for any partial or full month or for any period of time you may be absent from the Community including, but not limited to, periods of hospitalization...Your Apartment will continue to be reserved for and considered to be used by you until the Agreement is terminated pursuant to the termination provisions in Section 4". Section 4 of the Admission Agreement indicated that "you may terminate this Agreement at any time and for any reason by giving us a written notice of termination at least thirty (30) calendar days prior to the date of the termination stated in your notice. You will continue to be responsible for payment of all charges, fees, and expenses incurred by you during such thirty (30) calendar day notice period or until you have moved from the Community and removed all of your possessions from the Community, whichever is later". R1's Resident Move Out Form indicated that they moved out on April 4, 2026 with the Bill Through Date of April 21, 2026. *********************************************Continued on LIC9099-C************************************************** Interviews with ED and the Resident Services Director (RSD) indicated that the facility communicated with R1's responsible party that R1 would require a higher level of care if they returned from the hospital. R1's relevant party indicated that the facility stated R1 would require outside care beyond what the facility provided if R1 returned to the care home. The ED indicated that they did not issue an eviction notice to R1 or their responsible party. ED and RSD indicated that R1's responsible party provided the facility with a 30-day written notice. According to R1's LIC602A dated April 1, 2026, R1 would require two (2) person assist with transfers as well as assistance with feeding. R1's Admission Agreement indicated that the facility's acceptance and retention criteria is that the resident "must be independent with activities of daily living (ADLs) or need the assistance of no more than one person with ADLs" and they "must have the ability to feed him or herself". According to R1's Account Summary, dated November 25, 2025-April 23, 2026, R1 had an outstanding balance due of $932.60 in January 2026. R1 had an overpayment of $338.16 in February 2026 and $724.44 in March 2026. R1 was not charged for Level 4 care, Level 2 medication assistance, or laundry services in April 2026. R1 was charged a prorated amount for rent in April 2026 from the 1st-19th of $2870.30 plus a late fee of $66.98. R1 was credited $130 after the overpayments in February 2026 and March 2026 were applied to the balance due in February 2026. R1's total balance due for the month of April 2026 is $2807.28. Based on documentation reviewed and interviews conducted, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 59-AS-20260410122609

Allegation investigated: -Staff did not provide alternative housing resources in eviction notice issued to resident -Facility is not providing toilet paper to resident

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Dana Stansel, to deliver complaint investigation findings regarding the above stated allegations. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. LPA received a copy of the of the eviction notice sent to resident (R1) along with the signed certified mail proof of service dated May 13, 2025. The eviction notice provided indicated an alternative housing and care option in the area. LPA interviewed R1 who indicated that toilet paper is supplied to them. R1 indicated that, if they run out of toilet paper, they ask staff and will be provided more. LPA interviewed housekeeping who indicated that they provide two (2) rolls of toilet paper per week. Housekeeping indicated that when a resident needs more they will provide additional rolls. Based on documentation reviewed and interviews conducted, the above allegations are found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Nov 4, 2025 · control 59-AS-20251015145948

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director (ED), Dana Stansel, to conduct a case management visit in relation to a separate inspection conducted on today’s date, November 4, 2025. LPA reviewed resident (R1's) documentation. The facility provided R1's progress notes indicating that R1 was sent to the hospital on January 14, 2025, due to increased confusion and hallucinations. R1 was reassessed by the facility on January 22, 2025, which indicated that R1 required assistance three (3) times per day for orientation "mild/moderate impairment of memory, disorientation, and may display anxiety with memory difficulties. May be perceived as oriented, but memory deficits seen over time. Requires some prompting and encouragement 1 to 3 times per day". R1's previous assessment conducted on March 28, 2024 did not indicate that resident required assistance. R1's Physician's Report LIC602A dated January 6, 2022 indicated that R1 had mild cognitive impairment and did not exhibit confusion/disorientation. R1's Physician's Report LIC602A dated January 21, 2025 indicated that R1 had a primary diagnosis of Dementia and exhibits confusion/disorientation. Interview with ED indicated that R1 required additional care due to progression of Dementia diagnosis. The facility implemented additional care for R1. According to R1's Identification and Emergency Information LIC601, R1 is their own responsible party for financial affairs, payment for care, and their own legal guardian. R1's LIC601 also included family members to notify in an emergency. Email correspondence indicated that the facility was aware that R1's family member was attempting to gain Durable Power of Attorney (DPOA) in order to assist R1. According to invoices provided by the facility, R1 was on an automatic payment plan. The automatic payment did not go ************************************************Continued on LIC809-C******************************************** through on February 5, 2025 and was returned on February 8, 2025. R1's automatic payments continued to be returned until April 10, 2025. Due to non-payment, the facility began the 30-day eviction process sending notification to R1 via certified mail on April 28, 2025. The facility did not provide LPA a signed certified mail proof of service for this date. An additional 30-day notice to pay or quit was sent to R1 via certified mail on May 7, 2025 and the certified mail received was signed by R1 on May 13, 2025. The facility filed an unlawful detainer complaint with the Superior Court of California County of Sacramento on July 22, 2025. According to Proof of Service of Summons, R1 was personally served a copy of the summons, complaint, civil case cover sheet, and plaintiff's mandatory cover sheet and supplemental allegations unlawful detainer on July 24, 2025. The Proof of Service of Summons indicated that R1 was served at their home as "a competent member of the household (at least 18 years of age) at the dwelling house or usual place of abode of the party. I informed him or her of the general nature of the papers". R1 has a Dementia diagnosis as of the LIC692A dated January 21, 2025 with confusion/disorientation and also had a family member in the process of obtaining DPOA status who was not sent the 30-day notice or unlawful detainer complaint documentation. Interview with R1 indicated that they do not check their mail frequently and that they have been receiving documents that they do not understand. R1 indicated that they received documents saying they owe something. R1 believed it was for furniture purchased in the 1970s when their spouse was living and expressed they were afraid they could go to jail. R1 indicated that they have not purchased any furniture recently and that their spouse has passed away. Observation of R1 indicated that they were exhibiting confusion. The facility provided LPA with all court documentation pertaining to the unlawful detainer complaint and there were no indication that the court was notified of R1's current primary diagnosis. R1's progress notes indicated that they were sent to the hospital on September 19, 2025 due to increased confusion and strong urine odor. Progress notes also indicated that on September 21, 2025 R1 was noted to have a urinary tract infection and prescription medication was ordered. Interview with ED indicated that the facility had a meeting regarding over reporting and indicated that this incident was not reported to CCLD. CCLD does not have record of the September 19, 2025 incident. LPA had a conversation with ED regarding reporting requirements and ED agreed that the facility will begin reporting all hospitalization incidents to CCLD. As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are listed on 809-D pages. Exit interview was conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 18, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure resident (R1) was being treated with dignity when R1 had a change in cognition and facility did not consider change during eviction process, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: Facility will submit a plan to ensure that residents' rights are not being violated when they have a change in cognition and provide to LPA by the POC due date of 11/18/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(3) · Plan of correction due date: Nov 18, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation..or other actions of a punitive nature... This requirement is not met as evidenced by: Based on records reviewed, the facility provided a 30-day notice to pay or quit indicating that if resident (R1) does not pay by the date and time indicated that R1 is required to move or surrender possession of their apartment, or if payment is not made in full they are no longer allowed to remain in the community, and they must vacate and deliver possession of their apartment, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: Facility will provide a draft of a 30-day eviction notice, that is not a notice to pay or quit, indicating the notice is due to non-payment and remove the intimidating verbiage. Sample notice will be used in future instances of eviction for non-payment. Facility will send a copy to LPA by the POC due date of 11/18/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 18, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the facility did not ensure that they notified CCLD of R1's being sent to the hospital on 9/19/25, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: Executive Director indicated that they will ensure all reporting requirements are being followed. Facility will submit a statement of understanding by the POC due date of 11/18/25.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced and met with the Executive Director, Dana Stansel, 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, two (2) bedrooms in memory care, and seven (7) common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 112.7 degrees F in building A and memory care, 118.3 degrees F in building B, and 110.5 degrees F in building C. 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, Oct 22, 2025

Allegation investigated: Staff did not seek medical attention for a resident in care. Staff does not allow resident access to their bedroom. Staff did not assist a resident in a timely manner.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete and deliver findings to a complaint received on May 5, 2025 and met with Dana Stansel, Administrator, stating the reason for the inspection. During the investigation, LPA interviewed the Administrator, Memory Care Director, (3) staff, a hospice nurse and resident (R1). LPA also reviewed paperwork from resident (R1's) facility file, including the physician's report, care plan, several incident reports related to recent falls. The results of the investigation are as follows: Resident (R1) moved to the Assisted Living side of the community on November 30, 2024. After several repeated falls in March/April 2025, and being placed on hospice on April 8, 2025 and, resident was subsequently moved to the facility's Memory Care Unit. Diagnosis listed on the physician's report (April 14, 2025) note resident had Cerebral Atheroslerosis, hallucinations, repeated falls, hypertension and chronic pain syndrome. Resident passed on May 30, 2025, under hospice care. *cont on 9099C-1. Unsubstantiated 9099C-1.. Allegation: Staff did not seek medical attention for a resident in care. The allegation states on Friday 05/02/2025, resident (R1) was "throwing up" after eating lunch, did not eat any food for two days and was very weak, and the staff did not take (R1) to see a doctor. Facility documents show that (R1) was placed under hospice care on April 8, 2025 and remained under their care until they passed on 5/30/2025. (R1) stated to LPA on 5/8/25, "Yes, I was really sick- I called my daughter, who was very concerned". (R1) stated she got sick after she ate soup and then "only had liquids for the next couple of days and asked for water". One staff stated on 5/8/2025 that she is "not aware" of (R1) getting sick recently, and there have been "no changes" with resident's eating or drinking. A second staff was asked about (R1) getting sick and vomiting and commented, "it was only a phlegm- it was not vomiting- it was only one time, after lunch and before dinner. Hospice is aware". This staff explained that (R1) "likes coffee every morning and ate lunch that day", adding (R1) also likes soup, will eat a small lunch and sometimes also a small dinner. This staff explained "every time (R1) asks for juice or a snack, we give it to (R1)" and snacks are offered two hours after each meal also, and commented "we serve soup often". A Med-Tech staff stated she recalls (R1) getting sick one time, after lunch, in early May 2025 but is not sure what caused (R1) to get sick. This staff stated (R1) would have "still been offered food and (R1) played with their food" a lot. A friend of (R1) stated she visited (R1) on 5/2/2025 and observed that (R1) did not feel well and stated (R1) suffered from constipation which can cause vomiting. This individual stated that (R1) was very confused on this day and did not get sick from soup but from fish they ate and was not eating after getting sick. This person also stated that one staff told her they don't have enough staff to help take (R1) to the bathroom, which contributed to the constipation problem. *cont on 9099C2. 9099C-2.. (R1’s) family member stated she doesn't recall (R1) being sick on May 2, 2025 as (R1) has been under hospice care for 2 months, before moving to Memory Care Unit (MCU) from Assisted Living Unit (ALU) at the facility. The family member asserted "the MCU staff is good about calling me and would have called me if (R1) had gotten sick". Additionally, the family member stated she was visiting from out of state from Thursday to Sunday, prior to Monday, 5/5/25, and did not observe (R1) to be sick at all. Based on information obtained, LPA finds the allegation to be 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. Allegation: Staff does not allow resident access to their bedroom. The allegation states the resident (R1) is high risk for falls and requires a staff to supervise them at all times. The allegation also states that (R1) often makes requests to go to their room, staff does not allow (R1) to go to their room and is required to sit in the living room in their wheelchair for the entire day. The memory care director stated (R1) can't be left in bed, due to hallucinations and when (R1) is trying to ambulate, (R1) is falling. The Director asserted "No, (R1) is not prohibited from going in her room- we put (R1) in a recliner so (R1) can watch television". The Administrator explained "(R1) is a super friendly, fun lady- she is watched more and doesn't fall" when in the common area. One care staff explained "there is not enough staff to be with her to have a 1:1, so in the living room, we always have eyes on (R1) and stated staff has to be with (R1) all the time. A second staff confirmed that (R1) was kept in the common area due to being a fall risk and (R1) would try to get up and then slip. The Administrator stated the goal of memory care is to have as many residents as possible engaged with other residents in the common area. Residents will thrive better and have more eyes on them when in the common area, but staff will take residents to their rooms if requested. *cont on 9099C-3.. 9099C-3.. On 5/8/2025, (R1) stated to LPA, "Yes, they tell me I can't go in my room and I have to be in the common area". LPA observed (R1) to be "slouching" in her wheelchair. (R1) stated she will be starting Physical Therapy soon and commented, "the wheelchair is making me weak" and confirmed they are no longer using a walker. (R1) explained that staff tell them to "sit up" and doesn't like the "wedge" (pillow) staff use. A hospice nurse stated staff always take (R1) to the common area during the day when they visit and confirmed (R1) uses a wheelchair regularly, and slumps over, so “uses a Palmer cushion", to keep them upright. A friend of (R1) stated on 4/29/25, that (R1) was "very confused and crying and was awake all night". There were (3) caregivers there and they put (R1) in the common area for many hours. (R1’s) family member stated (R1) "was never told she could not go in her room and feels like a visitor put the idea in (R1's) head", commenting "(R1) hallucinates a lot". Based on information obtained, LPA finds the allegation to be 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. Allegation: Staff did not assist a resident in a timely manner. The allegation states that resident (R1) has a rash on their back, has a topical medication prescribed, and (R1’s) rash is getting worse due to sitting in their wheelchair all day. The allegation further states that on 05/02/2025, (R1) made a request to go to the bathroom and the staff made (R1) wait as they were chatting. There were no staff names provided. The Memory Care Director stated to LPA on 5/8/25 that on Friday, 5/2/25, when (R1's) friend told her she didn't feel (R1) "was getting enough attention and soon enough" and asked staff to toilet (R1) during her visit. The Administrator, stated that (R1) moved to the Memory Care Unit because they were falling in Assisted Living Unit and explained (R1) was "slumping out of their wheelchair". LPA observed (R1) to be using a device to assist with staying upright in the wheelchair when (R1) was observed on 5/8/25. *cont on 9099C4... 9099C-4.. The Memory Care Director stated that if a resident is scratching, they will be treated with anti-scabies creme and (R1) was prescribed Atarax creme, which is anti-itch and commented that (R1) continues to complain about itching, so she will request that hospice nurse talk to the doctor about changing the creme. One care staff confirmed on 5/8/2025, "Yes, (R1) has a rash on her back. (R1) has creme and Med-Techs are putting the creme on". This staff stated she is not sure of the number of cremes that were used, but "one had to be left on overnight", and the hospice CNA gave (R1) a shower the next day. This staff stated staff take (R1) to the use the bathroom when they ask staff, and there are (6) staff, including Med-Techs, that work in Memory Care Unit and (R1) wears a brief but will also use the toilet.A second staff stated on 5/8/25 that hospice gave (R1) a 7-day ointment that help prevent itching, and the rash is "much better now than 3 weeks ago". (R1) was asked if staff take them to the restroom when they ask and replied, "Yes, they help me go to the bathroom" and confirmed they had a rash and it was "itchy". (R1) stated they had "a shot and three different kinds of creme" used so far on the rash and will be starting Physical Therapy soon commented, "the wheelchair is making me weak". (R1) explained that staff tell them to "sit up" and they don't like the "wedge" (pillow) staff use. A Med-Tech staff stated she does not recall that (R1) was constipated or needed medications to help with constipation. This staff stated she regularly helped (R1) use the restroom and (R1) never complained of constipation but instead complained of indigestion and would ask for soda, 7 up, Ginger Ale and crackers. This staff stated staff would assist (R1) 2x/shift in using the bathroom, before/after meals and when requested, and (R1) was "generally cooperative". This staff stated no other resident or any staff had a scabies diagnosis during this time frame. A hospice nurse stated (R1) "had the rash before hospice" and when (R1) went on hospice, the hospice doctor made a referral to a dermatologist; however, the dermatologist never came out to see (R1) due to a billing issue". The hospice nurse stated (R1) was not given a scabies test but was treated two times for "suspected scabies" and administered Permethrin. This nurse responded that he goes to Atria "frequently" and often has "five to seven residents" he sees at one time and staff are regularly assisting (R1) and commented "Atria is on top of checking residents" to go to the bathroom. *cont on 9099C-5.. 9099C-5.. A friend of (R1) stated on 5/21/25 that (R1) has been "itching" a lot and it "could be scabies", and that (R1) was treated for scabies two times. The friend stated (R1) complained over the phone to her that she "can't sleep" as the rash did not disappear after "two treatments", and Hydrocortisone was given as if the doctors were treating an allergy. A Med-Tech staff confirmed (R1) had a rash before starting hospice, and she applied prescribed creme to (R1's) arms, back and chest where there were red spots. This staff indicated she never saw (R1) scratch but would always complain their skin was itching. This staff also described the treatment where staff applied the creme and the next day, the hospice CNA gave (R1) a shower to rinse of the treatment. This staff stated another treatment had to be repeated. (R1’s) family member stated the facility "never mishandled" the rash, and the hospice doctor, was "already looking at the rash when it broke out" and every time he would visit (R1). The family member stated (R1) was placed under hospice care before the rash appeared and over the last two weeks, the rash has improved a lot and there is currently "no rash". The family member stated (R1) was given multiple ointments for the rash and treated for "scabies three times", adding (R1) was placed on hospice due to hallucinations and falls, and due to the hallucinations was "scratching a lot", which may have caused the rash. The family member was not sure if a scabies test was ever done but commented she felt there was "no neglect or abuse" and the facility "has been very good with all". Based on information obtained, LPA finds the allegation to be 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. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 59-AS-20250505122845

Allegation investigated: Staff inappropriately handled resident resulting in resident sustaining fracture.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on March 19,2025. LPA met with Dana Stansel, Administrator, and stated the reason for the inspection. During the investigation, the Department interviewed multiple facility staff, including managers, and (3) residents, including resident (R1) who is the subject of the investigation. Additionally, the Department reviewed facility documentation and hospital medical records related to (R1). The results of the investigation are as follows: Resident (R1) moved to the community in November 2023 with diagnoses of Rheumatoid Arthritis and Osteoporosis, A-fib, chronic back pain and Mild Cognitive Impairment. The results of the investigation are as follows: *cont on 9099C-1.. Unsubstantiated 9099C-1.. Allegation: Staff inappropriately handled resident resulting in resident sustaining fracture. The allegation states after resident (R1) vomited in the dining room, staff (S1) came to assist and grabbed (R1's) arm and yanked it and (R1) has had pain in their arm since this incident. (R1) requested to be sent to the hospital on 3/12/2025 due to experiencing weakness, pain in their right hand and a cold. Documentation reviewed shows (R1) was sent to the Emergency Room on 3/12/25 for the chief complaint of weakness and right hand pain. An x-ray revealed (R1) had a possible distal and radial ulnar fractures. Facility records, specifically the physician's report, showed that resident had a prior diagnosis of rheumatoid arthritis and osteoporosis. (R1) indicated they threw up in the dining room, but the Department was not provided with a specific date for this incident. The Administrator stated this incident occurred late January or early February 2025. (R1) stated that staff (S1) "responded to assist resident and grabbed their arm, ignoring resident's request to let go due to it causing them pain. (S1) denied grabbing or pulling on resident's arm, or physically abusing (R1) at any time,insisting she only "lightly touched" (R1's) hand. (S1) stated she was about to wipe resident's hand when (R1) told her to stop and she let go. The Administrator indicated (S1) went to get some wipes to assist (R1) and her touch was "very mild" when wiping (R1's) hand. Another resident (R2), witnessed the incident, and her statements corroborated with (S1's) statements. Additionally (R2) stated they did not feel (R1) was physically abused or mistreated. The Executive Director/Administrator confirmed that staff (S1) did not have any prior complaints from other residents or staff. The Administrator explained that resident (R1) also did not report the suspected physical abuse until a month had passed and it was reported following a separate incident between (S1) and (R1) where (R1) felt (S1) had offended them by a comment she made. It was unknown how or when (R1) sustained the injury. Based on information obtained, the allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation 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. *cont on 9099C-2.. 9099C -2... During the interview process of the investigation, the Department received the following additional information that is unrelated to the allegation in this report, as follows: Resident (R1) reported that staff, (S3) and (S4) were verbally abusive to them and staff (S4) grabbed their right arm. No other details provided. LPA interviewed staff (S3) and (S4) who stated that they would both assist (R1) with repositioning in their bed. Both staff stated that (R1) would sometimes refuse assistance and staff would not force (R1) since it's right to refuse. One staff stated they would let (R1) take their time and assist when they were ready for staff to help Both staff denied being verbally abusive to (R1) and said (R1) had moments where they "would be irritated" with staff and observed (R1) to be rude to many other staff. Both staff indicated they never grabbed (R1's) arm or saw any other staff do so. Based on information obtained, there was insufficient evidence to prove by a preponderance that this occurred. Resident, (R3), stated client (R4's) clothing and jewelry have been stolen. No details or dates of missing items were provided, but the incidents were allegedly reported to an unidentified facility staff but nothing has been done about it. (R3) indicated that (R4's) health has declined over the last 3 years and was not sure if this was related to the missing items. The Administrator stated on 8/21/25 that (R4) reported a missing shell sweater to her and that she found the missing item in (R4's) closet, which was stuffed, and took a picture and showed (R4). The Administrator was not aware of any other items belonging to (R4) that were reported missing. Staff (S3) stated that (R4) resides in a different building than where she or (S4) is assigned. The administrator confirmed the facility is following their theft and loss policy and logging items when they are reported missing. Based on information obtained, there was insufficient evidence to prove by a preponderance that this occurred.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 59-AS-20250319155453

Allegation investigated: Staff are not according resident privacy.

On May 29, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the finding for the allegation cited above. LPA met with Assistant Executive Director and explained the purpose of the visit. Based on interview conducted, R1 is stand-by assistance as R1 has history of vertigo and is placed in fall risk. R1's LIC 602 revealed R1 has motor impairment and/or paralysis due to "balance issues". Interview revealed, at time staff would knock then enter the apartment while R1 is in the bathroom with door opened. R1 does not mind if staff enters when R1 is in distress and needs assistance. Interview conducted with R2 revealed staff often would do a quick knock before entering but R2 would be in bed and wished to not be disturbed. Interview conducted with R3, R4, R5, R6, R7 and R8 revealed there are no concerns regarding privacy. Based on information gathered, the preponderance of evidence standards have not been met. Therefore, the allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 conducted and a copy of the report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 29, 2025 · control 59-AS-20241010160423

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on a recent incident report (LIC624) submitted to the Department on March 23, 2025. LPA met with Administrator, Dana Stansel, and stated the reason for today's inspection. LPA and Administrator discussed the incident when resident (R1) was not found in their apartment at approximately 8:30 pm on March 22, 2025. Staff had been checking on resident frequently all afternoon due to them showing agitation following a visit from family. Staff immediately contacted the facility management and resident's responsible person when resident was not located inside the community. An exterior search was then conducted and resident was found walking down the street at approximately 8:55 pm. Resident stated they just wanted to take a walk and returned to the community with staff but remained agitated and displayed signs of paranoia. Resident met with emergency medical services upon returning to the community and "exhibited clear cognition" while refusing medical treatment. Resident's responsible person decided to take resident to their home and provide 1:1 care/supervision to await physician guidance and later informed the facility resident was admitted to the hospital on March 24, 2025, for reasons unrelated to the incident. The Administrator stated (R1) moved in non-ambulatory on March 13, 2025 and was very cognizant. LPA reviewed a cognitive test taken on March 12, 2025 showing resident scored 27/30, which is in the "normal" range. Resident's physician's report (also dated 3/12/25) notes (R1) has Mild Cognitive Impairment (MCI), Trimalleolor fracture on the right lower leg, is not confused/disoriented, does not show inappropriate, aggressive or wandering behavior, and is able to follow instructions/communicate needs. It appears, the physician completed additional boxes related to a diagnosis of Dementia and not MCI. Based on documentation reviewed, it appears resident had cognitive functioning within normal limits. There is not a citation issued in this report. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 8, 2025

Allegation investigated: Staff are not mitigating the spread of infectious outbreaks in the facility.

On 02/06/25, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced at the facility to deliver the findings on the allegation cited above. LPA met with Sr Executive Director- Dana Stansel and explained the purpose of the visit. During the course of this investigtaion, LPA conducted residents and staff interviews and file reviews. The result finding of the allegation is as follow on LIC 9099-C. Unfounded ***Report Continued from 9099...... Allegation- Staff are not mitigating the spread of infectious outbreaks in the facility. The Department conducted record review and interviewed three staff and three residents regarding this allegation. Complaint alleged that staff were not following infection control guidelines to mitigate the spread of outbreaks at the facility around Thanksgiving 2024. Three staff interviews indicated that there were 3-5 residents who got sick with stomach bug in November 2024 in Assisted Living but there were no confirmed cases of Norovirus outbreak for residents. It was learnt that facility reported all those cases to Department per requirement and sought appropriate medical care for those residents who were sick. Staff interviews indicated that they were following infection control guidelines per facility’s policy and there were no concerns in that area. Department interviewed three out of five residents who were sick with stomach bug, and they all stated that facility provided the necessary care and services to them and did not express any concerns. Department was unable to interview two other residents who were sick at that time as one had moved out from facility on 12/31/24 and other one was not available for interview. Based on this information, it has been evaluated that facility staff followed infection control guidelines regarding this matter and there were no concerns, therefore this allegation was found to be UNFOUNDED. Based on information obtained, LPA finds the allegation to be UNFOUNDED-means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 6, 2025 · control 59-AS-20241210094329

Type of visit: Case Management - Incident

On 10/30/2024, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to conduct a case management follow-up visit in regards to the visit conducted on 9/20/2024. LPA met with Executive Director, Natasha Georges and explained the purpose of the visit. During today's visit, LPA and Executive Director discussed the closure of the death report visit as R1 was found unresponsive during a meal check as facility has a policy of checking on residents in care if a meal was missed. LPA observed R1 to have POLST with "do not resuscitate". No deficiencies observed. Exit interview and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 30, 2024

Type of visit: Required - 1 Year

On 10/30/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual inspection utilizing the care tool. LPA met with Executive Director and explained the purpose of the visit. Today's census is 191 residents in care with eight residents on hospice services, facility is licensed for 325, hospice waiver of 20. During today's inspection, LPA and Executive Director conducted a tour of the interior of the facility to ensure health and safety of residents in care. LPA and Executive Director conducted an inspection of facility kitchen, salon, theater room, laundry rooms, library, medication rooms, ten residents room, and the common areas. LPA observed facility to be at a comfortable temperature of 73*. LPA observed facility to have the required posters in the hallway by the common area. LPA observed facility to be clean and sanitary. File review conducted for 12 residents records and 10 personnel records. LPA reviewed Facility's Emergency Disaster Plan 2024 and Elopement and Fire Drills. LPA observed documentation of quarterly drills conducted for 2024. At this time, LPA is requesting a copy of facility's liability insurance to be emailed to LPA by Friday November 8. During room inspections, LPA and Executive Director observed sharps in R1's room. Additionally, LPA was informed if residents in care does not have mild cognitive impairment and/or dementia they are able to store own detergents. This matter will be under review. No deficiencies cited. Exit interview and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 30, 2024

Type of visit: Case Management - Incident

On 9/20/2024, Licensing Program Analysts (LPAs) Cassie Yang and Cassie Mikkelson arrived at the facility to conduct a case management visit regarding a death report the Department received on 09/19/2024. LPAs met with Executive Director, Natasha Georges and explained the purpose of the visit. During this visit, LPAs conducted a file review of R1's file and obtained a copy of the following: R1's LIC 602 R1's Needs and Assessment R1's Preplacement Assessment R1's POLST R1's Emergency Contact R1's Skilled Nursing Discharged Report At this time, LPAs are requesting a copy of the following to be emailed to LPA Yang by Monday 09/23/2024: Staff schedule with contact information for 9/17/2024 and 9/18/2024 The following incident is still under review by the Department. Exit interview and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 20, 2024

Allegation investigated: Staff is not meeting the needs of the residents

On 8/29/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings on the allegation cited above. LPA met with Executive Director and explained the purpose of the visit. During the course of this investigtaion, LPA conducted extensive interviews and file revies. The result finding of the allegation is as follow on LIC 9099-C. Unfounded LIC 9099-C Allegation: Staff is not meeting the needs of the residents. The Department conducted interviews regarding the allegation above. Based on interview conducted with Executive Director, it revealed that R1 had an incident in the restroom and R1 thought the pendant was pressed for help. Interview further revealed that in the restroom there is a pull cord that triggers a help signal but R1 did not use it nor did R1 contacted the front desk for assistance via telephone. Executive Director stated a help signal training will be provided for residents in care. Interview further revealed that R1 is not in incontinence care where this was a rare occasion. Interview conducted with R2 revealed R2 has had no issues getting staff assistance. Interview conducted with R3 and R4 both revealed there is no concerns with their needs as staff are helpful. File review revealed that there was no record of R1's pendant was triggered during the time of the incident. File review further revealed that based on the calls triggered by R1's pendant from May 2024 to date of incident, the longest response time was four minutes. File review of R1's LIC 602A PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY revealed that R1 has the capability for self care and is able to care for own toileting needs. Based on information obtained, LPA finds the allegation to be UNFOUNDED-means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 59-AS-20240716102800

Type of visit: Case Management - Legal/Non-compliance

On 5/22/2024, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a required quarterly case management visit in accordance with the Stipulation and Order, effective date 06/01/2022 to 06/01/2024. LPA met with the Executive Director (ED), Natasha Georges, and explained the purpose of the visit. During today's visit, LPA reviewed facility's stipulation binder and reviewed the orders of the stipulation. LPA observed facility audits of emergency call responses, care records and incident reports. LPA observed E-call testings to be completed for residents in care for month of April 2024. LPA observed last reporting of response call exceeding 10 minutes to be sent to Licensing on 5/17/2024. LPA observed in-service training regarding PHB, Valve Shut off- to be conducted on 5/9/2024. LPA observed the signatures of staff present. LPA observed the facility to be clean, safe, sanitary and in good repair at all times. LPA observed the stipulation to be posted in a conspicuous space. LPA and Executive Director discussed the upcoming end of facility's probation term. LPA informed Executive Director once probation has ended, a new facility license will be generated and mailed to the facility. As a result of today's visit, LPA observed the facility to be in compliance to Stipulation and Waiver and Order. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 22, 2024

Allegation investigated: Illegal eviction Staff did not provide resident's responsible party with resident's records.

On 5/1/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to the facility to deliver the finding of the allegations cited above. LPA met with Executive Director, Natasha Georges, and explained the purpose of the visit. The course of this investigation, LPA has conducted interviews and extensive file review. Results are as follow, please see LIC 9099-C. Unfounded LIC9099-C Allegation : Illegal eviction The Department conducted interviews and file review of the following allegation. Interview conducted with Assistant Executive Director, it revealed that R1's rent has not been paid for an extensive amount of time. Interview further revealed that R1 had a professional fiduciary as Durable Power of Attorney who conducted financial abuse and neglected to pay R1's monthly rent. File review revealed the last payment made by R1's fiduciary was February 2022. File review further revealed R1 and responsible party was provided a copy of the 30 Day Notice To Pay Or Quit letter in April 2022, September 2022. Notice of Intent To File Unlawful Detainer Action was provided to R1 in November 2022 and Notice of Filing Unlawful Detainer Complaint was filed and provided to R1 in January 2023. File review further revealed Sacramento Sheriff Department provided a Notice to Vacate to R1. Therefore, the allegation is unfounded. Allegation: Staff did not provide resident's responsible party with resident's records. The Department conducted interviews regarding the allegation cited above. Interview conducted with Assistant Executive Director revealed that R1's responsible party had requested for R1's "medical records". Assistant Executive Director stated that the facility does not have access R1's medical records as only the hospital will have the following records. Interview further revealed that Resident Service Supervisor was asked to make copies of R1's LIC 602 Physician Report, original Physician Orders for Life-Sustaining Treatment (POLST) and medication list for R1's repsonaible party. Interview conducted with Resident Service Supervisor revealed that documents request was provided to R1's responsible party "several times". Interview further revealed that the documents provided was R1's LIC 602, medication list, tuberculosis test result. Additionally, in another occasion, LIC 602 was emailed to R1's responsible party. The allegation is unfounded. Based on information obtained, LPA finds the allegation to be UNFOUNDED-means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted, a copy of the report was provided.the state’s words, verbatim · CDSS document, May 1, 2024 · control 59-AS-20230920125329

Allegation investigated: Facility is not allowing resident to leave the facility.

On 3/14/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the finding regarding the allegation the department received. LPA met with Executive Director, Natasha Georges, and explained the purpose of the visit. During the investigation, LPA conducted extensive interviews. Result of the investigation is as follow. Please continue on LIC 9099-C... Unfounded LIC 9099-C... Allegation: Facility is not allowing resident to leave the facility. The Department conducted extensive interviews regarding the allegation of the complaint. Interview conducted with R1 revealed that R1 was stopped by Executive Director who did not allow R1 to leave the premises. Interview conducted with Executive Director revealed that Executive Director had stopped R1 and asked R1 to sign out prior to leaving the facility. Interview further revealed this best practice protocol is conducted on all residents to ensure their safe returning. Executive Director stated R1 became upset and Executive Director contacted the corporate office for further assistance and was advised to not continue enforcing R1 to sign out. Interview revealed R1 chose to not leave the premises after this incident as Executive Director informed R1 it is fine, he can leave but observed R1 entering back to the facility into the common areas. Interview conducted with Assistant Executive Director revealed that R1 was upset and did not want to cooperate with facility staff when asked to sign out. Interview conducted with R2 revealed that R2 does not have an issue leaving the facility. R2 stated that she and/or family member comply with the sign out protocol with no issue. Based on information obtained, LPA finds the allegation to be UNFOUNDED-means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted, and a copy of the report and appeal rights was provided via email.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 59-AS-20230703092623

Allegation investigated: Facility is not maintaining a comfortable temperature for a resident in care.

On 3/14/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the finding regarding the allegation the department received. LPA met with Executive Director, Natasha Georges, and explained the purpose of the visit. During the investigation, LPA conducted extensive interviews, file review and room inspections. Result of the investigation is as follow. Please continue on LIC 9099-C... Unfounded Allegation: Facility is not maintaining a comfortable temperature for a resident in care. The Department conducted extensive interviews regarding the allegation cited above. Interview conducted with R1 revealed that facility staff conduct daily checks on residents in care to ensure room are in a comfortable temperature. Interview conducted with R2 revealed that R2's AC unit is in an operable condition. Interview further revealed that facility provides residents in care portal air conditioning units during the summer if needed, and facility provides portal heating units for residents if they request for it. Interview conducted with Executive Director revealed that facility offer residents in care, the option to relocate to the B and C wings if needed as the A wing units' Heating, Ventilation, and Air Conditioning is older. Document review revealed that Executive Director had submitted a request for a replacement for the A wing Heating, Ventilation, and Air Conditioning. Based on interview conducted with Executive Director revealed that a request is to be approved, then a construction permit is needed prior to work getting done. Interview further revealed that facility accommodates to residents' needs if alternative heating and/or air conditioning is needed. Based on information obtained through interviews and file reviewed, the Department finds the allegation found the complaint to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of report and appeal rights will be provided via email to Administrator.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 59-AS-20230802163034

Type of visit: Case Management - Legal/Non-compliance

On 3/14/2024, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a required quarterly case management visit in accordance with the Stipulation and Order, effective date 06/01/2022 to 06/01/2024. LPA met with the Executive Director (ED), Natasha Georges, and explained the purpose of the visit. During today's visit, LPA observed the common areas to be clean, safe, sanitary and in good repair. LPA reviewed facility's stipulation binder and reviewed the orders of the stipulation. LPA observed an audit of total care staff hours and total care task for month of January 2024, February 2024 and partial of March 2024. LPA observed the facility to conduct daily audits of emergency call response and incident reports for residents if call exceeds ten minutes. LPA observed documentation of facility's staff training conducted in month of January 2024. LPA observed the recent report submitted to LPA, between February 20 - March 4, there was a total of 883 calls made, there was three calls exceeding ten minutes. LPA and Executive Director discussed the facility's current standing of nine days with no response call exceeding ten minutes. As a result of today's visit, LPA observed the facility to be in compliance to Stipulation and Waiver and Order. Exit interview conducted and a copy of the report will be emailed to Executive Director.the state’s words, verbatim · CDSS document, Mar 14, 2024

Allegation investigated: Facility staff are not keeping the facility at a comfortable temperature for residents Licensee does not ensure facility AC unit is in working condition

On 3/14/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings regarding the allegations the department received. LPA met with Executive Director, Natasha Georges, and explained the purpose of the visit. During the investigation, LPA conducted extensive interviews, file review and room inspections. Results of the investigation is as follow. Please continue on LIC 9099-C... Unfounded Allegation: Facility staff are not keeping the facility at a comfortable temperature for residents. Allegation: Licensee does not ensure facility AC unit is in working condition The Department conducted extensive interviews regarding the allegation cited above. Interview conducted with R1 revealed that facility staff conduct daily checks on residents in care to ensure room are in a comfortable temperature. Interview conducted with R2 revealed that R2's AC unit is in an operable condition. Interview further revealed that facility provides residents in care portal air conditioning units during the summer if needed, and facility provides portal heating units for residents if they request for it. Interview conducted with Executive Director revealed that facility offer residents in care, the option to relocate to the B and C wings if needed as the A wing units' Heating, Ventilation, and Air Conditioning is older. Document review revealed that Executive Director had submitted a request for a replacement for the A wing Heating, Ventilation, and Air Conditioning. Based on interview conducted with Executive Director revealed that a request is to be approved, then a construction permit is needed prior to work getting done. Interview further revealed that facility accommodates to residents' needs if alternative heating and/or air conditioning is needed. Based on information obtained through interviews and file reviewed, the Department finds the allegation found the complaint to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of report and appeal rights will be provided via email to Administrator.the state’s words, verbatim · CDSS document, Mar 13, 2024 · control 59-AS-20230519094241

Allegation investigated: Staff did not follow proper eviction procedures

On 01/05/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to open and deliver the findings of the allegation cited above. LPA met with Executive Director, Cristina Ortiz, and explained the purpose of the visit. Today's investigation, LPA conducted a file review and interviews with Administrator and R1. Result is as follow regarding Allegation: Staff did not follow proper eviction procedures Please continue on LIC 9099-C. Unfounded Allegation: Staff did not follow proper eviction procedures. Based on file review, it revealed R1 has missed the rent payment for the month of October 2023, November 2023, and December 2023. Interview conducted with Administrator revealed R1's Power of Attorney is aware that R1 is out of funds and is unable to pay rent at the facility. Interview with R1 revealed R1 is aware her Power of Attorney has not paid R1's rent for several months. Documents revealed that eviction letter was served on December 22, 2023 with effective date of January 22, 2024, which is 30 days, in compliance of Title 22 Eviction Procedures. Document further revealed eviction letter obtained the required criteria of referral services aid in finding alternative housing, complaint information to Licensing and Long Term Care Ombudsman, and lastly Health and Safety Code Section 1569.683(a)(4) unlawful detainer action. Based on information obtained, LPA finds the allegation to be UNFOUNDED-means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted, and a copy of the report and appeal rights was provided via email.the state’s words, verbatim · CDSS document, Jan 5, 2024 · control 59-AS-20231227082445

Type of visit: Case Management - Other

On 11/30/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to the facility to conduct a case management visit regarding a voicemail LPA received from Executive Director (ED), Kim Hagen. LPA met with Assistant Executive Director (Asst. ED), Cristina Ortez, and explained the purpose of the visit. LPA was informed ED was not in the community. Asst. ED contacted ED, who spoke to LPA on speaker phone. LPA was informed ED is relocating to a new community and Asst. ED will be interim ED for the time being. LPA was informed the required documents will be provided to LPA in a timely manner to appoint new Administrator. ED reported her exit date in the community to be 12/08/2023. LPA and Asst. ED then discussed a current concern regarding family visitation dispute with R1. LPA advised facility to keep documentation and submit incident reports if the events were to reoccur when a resident declined visitation but family members are refusing to leave the premises. As a result of today's visit, no deficiencies observed. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 30, 2023

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to conduct a required 1-year annual inspection. LPAs met with Senior Executive Director (ED), Kim Hagen , and explained the purpose of the visit. Facility is licensed for 325 non-ambulatory residents, hospice waiver of 20. Facility currently has 192 residents, 11 on hospice services. LPAs and ED conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: eleven (11) rooms in Memory Care/ Life Guidance unit, nine (9) rooms in Assisted Living, three (3) laundry rooms, two dining rooms, Salon, Movie Theater, Library, kitchen, mini Grab & Go Grille, Learning Center, Employee Lounge, and the courtyard. LPAs observed the facility to have the mandated posters posted in a conspicuous space. LPAs observed Administrator Certificate for ED to be expired. ED informed LPAs her certificate has been renewed but did not receive the copy. LPAs confirmed on CCLD website, Administrator Certificate #6050074740 is current with expiration date of 12/07/2024. LPAs informed ED LPA Yang will contact Admin Cert unit for a copy of ED's certificate. In areas toured, LPAs did not observed any violation of health, safety and personal rights. LPAs completed the CARE tool and found the facility to be in compliance at this time. No deficiencies observed. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 20, 2023

Type of visit: Case Management - Legal/Non-compliance

On 10/20/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived at the facility unannounced to conduct a required quarterly case management visit in accordance with the Stipulation and Order, effective date 06/01/2022 to 05/31/2024. LPAs met with the Executive Director (ED), Kimberly Hagen, and explained the purpose of the visit. During today's visit, LPAs observed the Stipulation and Waiver and Order to be posted in a conspicuous space in facility hallway. LPAs observed the facility to be clean, safe, sanitary and in good repair. LPAs reviewed facility's Stipulation binder and reviewed the orders of the stipulation. LPAs observed the facility to conduct daily audits of emergency call response. LPAs observed documentation of facility's monthly staff training. LPAs observed records of resident care task audit, staff numbers and observed sufficient staff per resident care needs. Additionally, LPAs observed incident reports submitted to LPA Yang for emergency call responses which exceeds 10 minutes. As a result of today's visit, LPAs observed the facility to be in compliance to Stipulation and Waiver and Order. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Oct 20, 2023

Type of visit: Case Management - Incident

On 10/20/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced to conduct a case management visit regarding the incidents reports the Department received on Tuesday October 17, 2023. LPAs met with Executive Director (ED), Kim Hagen, and explained the purpose of the visit. LPAs and ED discussed the serious/unusual incident report (SIR) submitted for an incident occurring on 9/10/2023 regarding R1’s emotional distress. LPAs discussed the importance of submitting SIRs in a timely manner as Title 22 mandates written reports to be submitting within seven days of occurrence. ED explained the dated of occurrence was inputted incorrectly as the incident occurred on 10/15/2023 not 9/10/2023. Additionally, LPAs and ED discussed the SIR submitted for an incident occurring on 10/16/2023 regarding the incident with medications in R2’s room. LPAs discussed the importance of informing family members that medications are to be locked and secured if resident is able to store own medications. ED informed LPAs R2 is a new resident in care, and is in the Med Program, meaning facility assist with medication administration. ED stated the medications found in the room where over the counter medications which was removed during time of observation. ED informed LPAs the facility notified family members immediately to remind them of facility's protocols. ED also stated primary care physician was notified as all medications need a doctor's order. LPAs and ED then discussed the LIC 624A Death Report received for R3. ED informed LPAs R3 was hospitalized beginning of the month due to a concern home health nurse observed. ED stated R3 was then discharged to a skilled nursing facility and then hospitalized again for the original concerns when R3 was at the facility. ED stated cause of death is unknown as R3 has not been at the facility for a few weeks. Please continue on LIC 809-C... LIC 809-C... At this time, LPAs requested a copy of R3's LIC 602, Emergency Contact, Needs and Assessment, all 2023 Incident Reports, list of meds, and Power of Attorney documents. LPAs informed ED to submit a copy of R3's Death Certificate once received by the family. This incident will be under review until further notice by the Department. During this visit, no deficiencies cited. Exit interview conducted and a copy of the report was provided to ED.the state’s words, verbatim · CDSS document, Oct 20, 2023