Atria Golden Creek

Type of visit: Case Management - Other

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver amended complaint findings for complaint control # 22-AS-20260413161414. LPA delivered amended findings to facility and reviewed the report with Executive Director Jeremy Gilmore. An exit interview was conducted and a copy of this report along with amended report was provided.the state’s words, verbatim · CDSS document, Apr 21, 2026

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

On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and Kimberly Lyman conducted an uannounced visit to deliver complaint findings. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. The Department received a complaint on 01/21/2026 and LPA Mendivil conducted the initial 10 day visit on 01/30/2026. During the course of the investigation LPAs interivewed staff and residents and obtained copies of resident records including service plan and physician's reports. Regarding the allegation faciltiy did not prevent resident falls due to lack of staff the investigaiton revealed the following: Per interview with Executive Director Jeremy Gilmore the current staffing levels for Memory Care is as follows: for AM 5 staff including 4 caregivers and 1 med-tech, PM 5 staff including 4 caregivers + 1 med-tech, and NOC 3 staff including 2 caregiver and 1 med-tech. Per interviews with 5 out of 5 staff stated they are able to meet residents needs and there are no issues with staffing. Unsubstantiated Per interviews with 2 out of 2 residents stated staff assisted them in a timely manner and their needs are met. Per review of Resident 1's (R1) physician report resident does not have motor impairment. Per service care plan R1 requires minimal fall assistance, per ED minimal assistance means escorting to and from dining and activities. Per review of incident reports R1 had 3 falls in between 02/13/2025 to 1/20/2026, R1 was taken to the hospital after each fall and R1's primary care physician was notified. The last fall occurred on 01/20/2026 around 1:00 PM, the resident was found on the activity room floor in Memory Care. R1 stated they were attempting to sit in a chair, missed the chair, and fell backward. Per incident report resident was sent out to the hospital after being assessed and assisted by staff at the facility. Therefore based on the preponderance of evidence through records reviewed and interviews the allegation Facility did not prevent resident falls due to lack of staffing is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 14, 2026 · control 22-AS-20260121131042

Allegation investigated: Uncleared staff providing care to residents

On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and Kimberly Lyman made an unannounced visit to conduct a compaint investigation. LPAs were greeted and granted entry into the faciltiy by staff and explained the reason for the visit. The Department received a complaint on 04/13/2026. During the course of the visit LPAs obtained copies of staff roster and reviewed a random selection of 6 staf members records. Regarding the allegation uncleared staff providing care to residents the investigation revealed the following: It was alleged that uncleared staff were providing care to residents, per review of staff criminal records clearance and staff roster all staff have obtained a criminal record clearance and are associated to the faciltiy. Therefore based on the preponderance of evidence through records reviewed the allegation uncleared staff are providing care to residents is determined to be UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility. Unfoundedthe state’s words, verbatim · CDSS document, Apr 14, 2026 · control 22-AS-20260413161414

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to conduct a required annual. Facility is licensed for 78 non-ambulatory residents. Facility has an approved hospice waiver for 10 residents.. Administrator Jeremy Gilmore has an administrator certificate expiring on 10/21/2027. LPAs Lyman and Mendivil along with Administrator Gilmore toured the facility at 10AM. LPAs toured the physical plant, checked food service, facility records and the first aid kit. The facility consists of three stories including a library, bistro, cinema room, game room and hair salon. Memory Care is accessible through secured door near dining room. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105 degrees F and 118.7 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Emergency pull cord response times were immediate. Common areas were clean and clear of hazards, doorways were free of obstructions. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility had posted appliance temperatures and all were in range. Dining room has varied menu choices for residents. Smoke detectors and fire/ sprinkler inspections are conducted by a third party on 02/03/2026. Fire extinguishers were fully charged. LPAs reviewed the emergency disaster plan and plan is thorough and complete. Facility conducts emergency drills with the last drill conducted on 03/20/2026. . LPAs observed ample emergency food and water. Outside grounds were toured. LPAs observed outside patio areas for both assisted living and memory care. There is ample outdoor shaded seating for residents. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. LPAs observed residents participating in activities and facility offers an array of activities including outings in the community. First aid kit contained all required items including tweezers, scissors and thermometer. LPAs reviewed ten resident files and six staff files. All resident files contained required documentation including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation including medical assessment, criminal record clearance and proof of CPR training. LPA Mendivil observed 5 out of 6 staff did not have required annual training hours. LPAs reviewed medication administration and storage. Medications are stored in locked medication carts and facility utilizes an electronic medication record. Medications appear to be administered per physician order. Based on the observations made during today's visit, deficiencies are being cited. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 14, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to conduct a required annual. Facility is licensed for 78 non-ambulatory residents. Facility has an approved hospice waiver for 10 residents.. Administrator Jeremy Gilmore has an administrator certificate expiring on 10/21/2027. LPAs Lyman and Mendivil along with Administrator Gilmore toured the facility at 10AM. LPAs toured the physical plant, checked food service, facility records and the first aid kit. The facility consists of three stories including a library, bistro, cinema room, game room and hair salon. Memory Care is accessible through secured door near dining room. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105 degrees F and 118.7 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Emergency pull cord response times were immediate. Common areas were clean and clear of hazards, doorways were free of obstructions. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility had posted appliance temperatures and all were in range. Dining room has varied menu choices for residents. Smoke detectors and fire/ sprinkler inspections are conducted by a third party on 02/03/2026. Fire extinguishers were fully charged. LPAs reviewed the emergency disaster plan and plan is thorough and complete. Facility conducts emergency drills with the last drill conducted on 03/20/2026. . LPAs observed ample emergency food and water. Outside grounds were toured. LPAs observed outside patio areas for both assisted living and memory care. There is ample outdoor shaded seating for residents. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. LPAs observed residents participating in activities and facility offers an array of activities including outings in the community. First aid kit contained all required items including tweezers, scissors and thermometer. LPAs reviewed ten resident files and six staff files. All resident files contained required documentation including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation including medical assessment, criminal record clearance and proof of CPR training. LPA Mendivil observed 5 out of 6 staff did not have required annual training hours. LPAs reviewed medication administration and storage. Medications are stored in locked medication carts and facility utilizes an electronic medication record. Medications appear to be administered per physician order. Based on the observations made during today's visit, deficiencies are being cited. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 14, 2026

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

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above for the purpose of delivering findings. LPA met with Executive Director (ED) Jeremy Gilmore. Regarding allegations, Staff mismanaging resident’s medications, Staff mismanaging residents’ medical records, and Staff not administering medications to residents according to physician’s orders, the following was revealed: it is alleged staff forged physician signatures, altered physician orders, postponed the construction of resident binders leaving incomplete paperwork, and delayed the destruction of narcotics. During the course of the investigation, LPA conducted a tour of the facility, including the medication room, and conducted file review for select residents. LPA observed medication to be centrally stored and locked in medication carts located within the medication room. LPA observed narcotics for select residents to be current and did not observe any narcotics pending destruction. (Cont. LIC9099-C) Unsubstantiated Interviews were conducted with thirteen staff and five residents. Five of five residents denied having any knowledge of staff forging physician signatures or altering physician orders. Three of five residents stated their facility file, and paperwork is complete to their knowledge and two of five residents stated they were unsure of what paperwork would be required. Nine of thirteen staff interviewed denied staff forging or altering physician signatures and denied having any knowledge of incomplete paperwork or delayed destruction of medication. One of thirteen staff stated they do not work with medication or resident paperwork and did not know if staff had forged or altered physician orders or signatures. Three separate attempts were made to contact three of thirteen staff, however, they could not be reached to confirm or deny allegations. Regarding allegation, Centrally stored medications are not kept in a safe and locked place, the following was revealed: Five of five residents denied the allegation and stated they have not seen any medication out of place or in common areas. Ten of thirteen staff denied the allegation and stated medication is maintained centrally stored and locked. Three separate attempts were made to contact three of thirteen staff, however, they could not be reached to confirm or deny allegation. During the course of the investigation, LPA did not observe any medication out of place or in common areas. Regarding allegation, Staff failed to report incident(s), the following was reviewed: It is alleged staff were prevented from reporting incidents, including behavioral and psychological changes, to residents’ family. During their interview, five of five residents denied the allegation and stated all incidents, including changes in their condition are reported to their responsible parties. Eight of thirteen staff interviewed stated incidents, including changes in condition, are always reported to the residents’ responsible parties and denied ever being personally instructed not to report an incident or having any knowledge of staff ever being prevented from reporting any incident. Two of thirteen staff stated they were not responsible for reporting incidents and did not know if all incidents were or are being reported. Three separate attempts were made to contact three of thirteen staff, however, they could not be reached to confirm or deny allegation. Regarding allegation, Residents have scabies, the following was reviewed: It is alleged the facility refused to admit the presence of scabies resulting in an unknown number of residents and five staff contracting scabies. Five of five residents interviewed have been residing at the facility since 2021 and denied the presence of scabies then and now. During the course of the investigation, five of five staff identified as having scabies were contacted. (Cont. LIC9099-C) Three of five staff stated they had contracted scabies while working the facility and had been provided with medical treatment by the Licensee, however, were unable to identify residents alleged to have also contracted scabies. Three separate attempts were made to contact two of five staff, however, they could not be reached to confirm or deny allegation. Regarding allegation, Staff failed to protect residents from harm, the following was revealed: It is alleged Staff 1 (S1) interacted with COVID residents and was then mandated to pass medication in the COVID-free residents. Three of five residents stated there was a division of staff working with COVID positive residents and a separate division of staff working non-COVID residents. Two of five residents denied knowing whether or not there was separation of staff working with COVID and non-COVID residents. Nine of thirteen staff interviewed denied having knowledge of alleged incident and stated there was a division of staff working with COVID residents and a separate division of staff working with non-COVID residents. One of thirteen staff stated they do not provide care to the residents and stated they did not know whether or not there was a division of staff. Three separate attempts were made to contact S1 and two additional staff, however, they could not be reached to confirm or deny allegation. Based on observations made during the course of the investigation, resident record review, and due to allegations being uncorroborated during interviews conducted, the Department is unable to determine if Staff mismanaged residents' medications, if Staff mismanaged residents' medical records, if Staff did not administer medications to residents according to physician’s orders, if Centrally stored medications were not kept in a safe and locked place, if Staff failed to report observed changes of condition, if Staff failed to report incident(s), if Residents had scabies or, if Staff failed to protect residents from harm. Although the above 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 at this time the above allegations are unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Feb 6, 2026 · control 22-AS-20210226151742

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

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit. The Department received a complaint on 08/27/2025 and LPA Mendivil conducted the initial 10 day visit 09/04/2025. LPA interviewed staff and residents and obtained copies of caregiver schedule for September/October 2025, admission agreement, cleaning/laundry schedule. Regarding the allegation facility lacks staffing in which resident needs are not be met the investigation revealed the following: It was alleged there is not enough staff to meet residents needs. Based on interviews with staff and Executive Director Jeremy Gilmore, there are about 35-40 residents that have care plans with varying levels of assistance needed in Assisted Living. Executive Director Jeremy stated there are 3 caregivers and 1 med-tech scheduled for AM shift and PM shift in Assisted Living and 2 caregivers and 1 med tech for overnight. Unsubstantiated Based on interviews with 6 out of 6 residents stated their needs are being met. LPA Mendivil interviewed 5 out of 5 caregiving staff and they all stated they are able to meet residents needs. 5 out of 5 staff stated they answer pendant calls in under 10 mins and there has not been a time when staff has left a resident soiled for an extended period of time. 5 out of 5 staff stated they are trained annually regarding providing assistance with activities of daily living. Therefore based on the preponderance of evidence through interviews the allegation that Facility lacks staffing in which resident needs are not being met is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 22-AS-20250827083931

Type of visit: Required - 1 Year

On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and Fred Arias made an unannounced visit to conduct a required annual. LPAs were greeted and granted entry into the facility and explained the reason for the visit. Licensed capacity is (155) current census (122). During today’s visit, LPA Mendivil along with Executive Director Jim Craddock toured the facility and inspected the physical plant, including but not limited to testing hot water temperature in five bathrooms. The hot water temperature measured between 110 and 118 degrees Fahrenheit. The facility’s last fire drill was conducted on March 12th 2025. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA Mendivil observed medication storage and reviewed the centrally stored medications for two residents. Per review completed medication appear to be being given as prescribed. LPA Mendivil observed activities in the form of group exercise, movie theater, hair salon and gym. LPA Arias reviewed six out of six staff records. LPA Arias conducted a complete review of eight resident records. LPA Mendivil confirmed that administrator has a current administrator certificate which expires on July 28th 2026 Based on the observations made during today’s visit no deficiencies cited on this date. An exit interview was conducted with facility staff and copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the Executive Director Dorice Redman facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with was granted entry to the facility. Licensed capacity is (155) current census (106). LPA was accompanied by Executive Director Dorice Redman to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated space for client/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed (8) client file for admission agreements, updated physician reports, and needs and services plans. LPA audit (8) medications. LPA also reviewed (5) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screening. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Executive Director Dorice Redman.the state’s words, verbatim · CDSS document, Jul 16, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Tea conducted a case management visit to follow up on an incident report received by Community Care Licensing (CCL) on May 24, 2024 submitted by Resident Service Director (RSD) Elaheh Mobadifar. LPA was greeted and allowed entrance into the facility by Executive Director (ED) Dori Redman. LPA explained the reason for the visit. The purpose of this visit is for a case management incident where a resident eloped from the facility on May 24, 2024 and was found by Staff 1 (S1), Memory Care Medical Assistant/Med-Tech still on facility property. LPA requested resident file and staffing schedule. LPA interviewed S1. S1 was alerted by a private caregiver (S2) of a resident in memory care, who was near by in the memory care dining room when the alarm had gone off. S1 saw that the alert was coming from the back gate with delayed egress. S1 discovered the resident standing on the parking lot by the back gate of the facility. The parking lot has no traffic and has only one car parked at the time. Resident was immediately safely brought back to her room and she immediately reported the incident right away. LPA interviewed resident (R1) to ensure she was okay. Resident did not recall the incident, she is diagnosed with dementia. R1 stated that she was okay and said that she wants to go home. She waved to S1 and told LPA that S1 is her friend who helped her get back to her room, which was her only recollection of the event. Reviewing R1's file she is unable to leave the facility unassisted. None of the staff did not see R1 leave the facility because residents are allowed to walk around the memory care. The back gate where she was found is part of the large court yard of memory care where residents can sit and walk around. LPA tested delayed egress of the back gate to see the staff response. Within less than a minute, staff came to check what was going on and to make sure everything was alright. They responded in an appropriate timely manner. Continuation of Case Management on LIC809-C Based on LPA observations and interviews there was adequate staffing at the time. Staff immediately responded to the alarm and followed protocol and immediately reported the incident right away to the department. Resident was still on the property of the facility and did not go off the property. Resident is safe and was monitored closely after the incident. No deficiencies are being cited as a result of this visit. An exit interview was conducted with Executive Director, Dori Redman and a copy of this report was provided with the LIC 811 at exit.the state’s words, verbatim · CDSS document, Jun 10, 2024

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

This is an amended report. This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by Receptionist Maria McKennett. LPA met with Executive Director, Dorice Redman (ED) and explained the nature of the inspection. The department received a complaint on 12/15/2020 alleging a resident sustained an injury from a fall while in care. The Reporting Party (RP) disclosed that a resident was hospitalized for major blunt trauma due to an unwitnessed fall. During the investigation, the department interviewed Executive Director, staff and residents. (continued on LIC9099-C) Unsubstantiated This is an amended report (continued from LIC9099) On 4/3/2024 LPA conducted interview with Executive Director (ED) Dorice Redman. ED stated that she started working at the facility in March of 2024. ED made no disclosures regarding allegation. LPA attempted to interview the Reporting Party (RP) twice by calling the phone number provided on 4/2/2024 at 1:31 pm and again on 4/3/2024 at 10:13am. LPA was told to expect a call back by the end of the day on 4/3/2024. LPA did not receive a call back. On 4/3/2024 LPA conducted interviews with Executive Director (ED) and facility staff. No disclosures were made regarding the allegation. LPA interviewed Resident 1 and Resident 2 who resided at the facility during the time of the allegation. No disclosures were made regarding the allegation. LPA could not interview the Alleged Victim (AV) because they passed away in December 2020. LPA obtained copies of the following files: resident roster, staff roster, staff schedule, incident reports, pre-placement appraisal, needs assessment, needs profile and physician's report. Based on record review, LPA determined R1 was diagnosed with dementia and required checks at approximately 12am, 2am, 4am and 6am. Based on interview with Staff 1, it was stated that R1 was checked on at approximately 4:30am on 12/12/2020 and that is when the resident was found on the floor. Based on interviews conducted and records reviewed LPA determined that the facility conducted their nightly checks and Staff 1 discovered Resident 1 on the floor. Therefore, there is insufficient evidence to indicate that this occurred as a result facility negligence. Although the allegation(s) may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and this report was reviewed with Executive Director. A copy of this LIC-9099 was provided to the facility.the state’s words, verbatim · CDSS document, Apr 26, 2024 · control 22-AS-20201215112452

Allegation investigated: Illegal eviction

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility by Executive Director Dori Redman and explained the reason for the visit. During the course of the investigation LPA toured the facility, interviewed Executive Director and resident as well as reviewed and obtained pertinent documentation such as facility notes. Regarding the allegation of Illegal eviction, the investigation revealed the following: Facility served a thirty day notice to Resident 1 (R1) on March 7, 2024 for violation of house rules regarding alcohol abuse. House rules verbiage indicates "abuse of alcohol will not be tolerated." LPA reviewed six incident reports outlining public intoxication and subsequent hospitalization from the episodes with the last one being March 6, 2024. Interview with R1 confirms episodes of intoxication. Facility documented ten instances of public intoxication between January and March 2024. Documentation includes advisement from staff to discontinue drinking alcohol. The department has determined that the eviction is legal. Therefore, the allegation is deemed unfounded, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Mar 15, 2024 · control 22-AS-20240308100024