Atria Rocklin

Allegation investigated: Staff did not prevent residents from engaging in a physical altercation Staff did not ensure reporting requirements were followed Staff threatened eviction on resident in care

On 07/15/26, Licensing Program Analyst (LPA) Graham Gunby arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Executive Director, Dana Stansel. During the investigation, the Department conducted interviews, observations an reviewed documentation pertinent to the investigation. *Continued on LIC9099-C* Unfounded Allegation: Staff did not prevent residents from engaging in a physical altercation Through the course of the investigation process, CCL conducted interviews, toured the facility, and reviewed records regarding the allegation above. The incident started with arguing between R1 and R2 then escalated to R1 being hit. Staff intervened at this point, trying to re-direct and calm the residents. It was determined that staff were in the vicinity, and when alerted to the incident responded and separated the residents. Staff reported the incident to management and the proper services were called. Allegation: Staff did not ensure reporting requirements were followed Throughout the course of the investigation the department reviewed records and conducted interviews with staff relevant to the complaint allegation. Staff interviews indicated that staff reported the incident to management who submitted a LIC624 to the Department, contacted EMS and POA. Record review revealed that facility submitted all required documents to the department per Reporting Requirements. Allegation: Staff threatened eviction on resident in care During interviews with staff, it was stated to the LPA that R1 and their family were not threatened with an eviction or given an eviction notice. It was stated that R1 was encouraged to increase their level of care due to the behaviors presented at the facility. Staff stated that they had a meeting with R1’s family and explained that R1’s behavior warranted an increased level of care. During interviews with witnesses, they stated that facility management stated R1 would need to either increase the level of care or move from the facility. The LPA asked the witness if R1 or the witness was given an eviction notice, they stated no, but moved R1 out of the facility due to the increase in cost. This agency has investigated these allegations. We have found that the allegations is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview with Executive Director. Report providedthe state’s words, verbatim · CDSS document, Jul 15, 2026 · control 59-AS-20260303115815

Allegation investigated: Staff are not meeting residents' toileting needs. Staff are not providing adequate food service to residents.

Licensing Program Analyst (LPA) Calzada arrived unannounced to complete the complaint investigation and deliver findings to a complaint received on July 21, 2025. LPA met with Cristina Ortiz, Administrator, and stated the reason for the inspection. LPA prepared the complaint findings at the facility in a large conference room before going over them with the Administrator. During the investigation, LPA interviewed multiple facility staff and residents in the Assisted Living Unit. LPA also reviewed pertinent documentation related to the allegations. The results of the investigation are as follows: Allegation: Staff are not meeting residents' toileting needs. The allegation states residents are not being changed timely (incontinent care), or are not being helped to the restroom timely. On July 19 and 20,2025, there was only one staff member working during the 2pm-6pm shift. *cont on 9099C-1.. Substantiated 9099C-1... One staff stated there are less than (10) residents that need toileting help and they have not seen any issues, and commented that the facility is "understaffed on the weekends, especially on the "pm" shift which has less people". This staff added that the "am" shift has the best caregivers" and they are more consistent; whereas on the "pm" shift, residents have to wait longer due to 1.5 staff only". Another staff confirmed that residents will call for toileting assistance sometimes in between their scheduled incontinent checks and feels all staff "do a great job" commenting "we all are pretty prompt" ; however, stated the "pm" shift is overwhelmed and overall the facility is short staffed. One resident (R1) stated to LPA on 10/24/25 (Friday) (3:30 pm) that they have not been provided with incontinent care since 8:00 am this morning when they woke up and a staff changed them. This resident confirmed they have pushed the pendant, but the facility is "short staffed on all shifts", asserting "they are supposed to change me (incontinent) four times per day" and provided LPA with the scheduled times and staff (S1) who always attends to them promptly, is off today, but usually brings them tomato juice in the morning. Staff schedules show (S1) works on the "am" shift, from Sunday through Thursday. (R1) stated to LPA that no staff had come to check on them, including bringing water, since 8:00 am this morning, pointing to their bedside table. Within (5) minutes of LPA speaking to (R1), LPA observed (3) staff knock and enter the room to offer incontinent assistance and empty the trash. Another resident (R2) stated they were not helped in the restrooms timely and complained a week ago Thursday, Oct 16, 2025, that there were "no caregivers on staff from 2:00 pm- 6:00 pm". This resident stated they "had an emergency" on the toilet and explained how they called the front desk and "no one answered" , until they told the Resident Services Director (RSD) and the Administrator, who brought them more toilet paper they were asking for. This resident also stated "no one answered the pendant" when they pushed it and added there are less staff on the "pm" shift, and staff are less trained" than the "am" shift. Based on information obtained, LPA finds this allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. *cont on 9099C-2.. 9099C-2. Allegation: Staff are not providing adequate food service to residents. The allegation states many residents complain about the food they are served due to it being not hot enough and being served at a lukewarm/room temperature. On July 24, 2025, LPA interviewed the administrator and Resident Services Director (RSD) about the food service. The administrator stated there is currently an opening for "Chef" in the Culinary Dept and one of the cooks stepped up temporarily to cover. Additionally, the administrator stated menu selections are updated on a weekly basis, and plates were previously sitting on the warmer and for an unspecified amount of time. The administrator explained the food service improved the beginning of July 2025- and they are "not plating the foot until the kitchen gets the order", and that there are "two daily specials- prepared in large quantities and kept on the steam table, and there is a daily Pre-Stand up meeting in the kitchen at 11:15 am. The RSD stated she is "not sure about the food temperature" and there was a "major change made in the beginning of July"- the change was so major that it's "more like a restaurant now - the food is not sitting on a warmer and was pre-plated before", and the improvement has to do with restructuring the way meals are ordered". LPA observed culinary staff, (S2), acting as the temporary lead chef, and (S3) present as a Prep Cook. (S2) explained to LPA how the "proofer" is used to warm resident plates to a temperature of 140*F before plating and serving the food. LPA observed (S2) to be preparing and plating food according to individual paper "tickets" displayed, and (S2) explained that culinary staff is "serving when the food is ordered, like a restaurant". (S2) indicated they have received "good feedback" on the new process and confirmed the shelf is hot- measuring 146*F. Also, on July 24,2025, LPA spoke with a few residents who were seated and eating lunch. One resident indicated the soup is "always hot" and that staff is "really kind" to residents and staff. A second resident stated she was served pizza and waffles the other day and it was "cold". On October 24, 2025, LPA interviewed multiple residents in the Assisted Living dining room during the lunch hour. Several residents stated the food temperature has improved over the last two weeks and the plates are now being warmed, which allows residents more time in eating their meal. A few residents stated they really like the breakfast choices but there are no low salt, diabetic options on the menu. *cont on 9099C-3.. 9099A-C-1. On 7/24/25, LPA requested resident pendant call response log was requested for the prior (30) days and was provided with (2) pages of a report entitled “Ave Response by Device by Category”. The report shows residents’ calls for assistance were responded to as quickly as (5) seconds and as late as (26) minutes and does not indicate what time of day/shift the resident calls were made. The administrator stated the (26) minute response was for a resident in Independent Living. The Resident Services Director stated staffing is scheduled as follows: AM: (3) caregivers and (2) Med-Techs (also help the caregivers); PM: (2.5-3) caregivers and (2) Med-Techs; and NOC: (1-2) caregivers and (1) Med-Tech. The RSD stated there are (50) residents in Assisted Living and (10-12) residents have "zero care needs", and some residents call for staff to raise the blinds in their room. Staff interviews revealed that staff is fairly quick to respond to calls on the “am” shift ; however, staff is often short staffed on the “pm” shift and so staff does not respond as quickly. Staff also indicated that residents have complained about having to wait longer for staff to assist. Staff stated they "used to have more non-emergency calls, but it has gone down- currently 5% of the calls are considered "emergency" where a resident has fallen or needs toileting assistance. Managers and a Med-Tech indicated that managers they will assist caregivers, when needed and everyone is cross trained. A Med-Tech stated there is a monitor in the med room and staff can see when a resident is calling for assistance. Also Med-Techs have a walkie (buzzes) to call the caregiver , and there are (2) Med-Techs in the morning who can help caregivers with what is needed as well as the Resident Care Coordinator and manager on duty who assists. The Med-Tech stated there are a lot of "non-emergency" calls where residents call for assistance with the light and water. Emergency calls are if a resident falls and the caregiver will respond, inform the Med-Tech who will go to their room and access, and call 9-1-1 if the resident fell or there is an emergency. This staff indicated staff respond within (10) minutes average. A few residents stated they were told they are "not supposed to use the pendant unless it's an emergency", with one resident stating "staff is "busy doing showers". One resident stated staff will respond within (5) to (15) minutes. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED-meaning although the allegation might have happened or is valid, the preponderance of evidence standards hasn’t been met. *cont on 9099A-C-2.. 9099AC-2.. Allegation: Licensee did not ensure that a comfortable temperature for residents was maintained at all times. The allegation states the facility was out of electricity from 5 pm to the early morning hours the next day. It was very hot inside the facility, the residents were very uncomfortable, and it appeared the facility was not prepared for this outage. LPA observed the temperature to be noted as 72-73*F inside when present in the facility on 7/24/25 and 10/24/25. (3) residents interviewed recalled the outage incident but did not recall the interior temperature becoming uncomfortable. Residents stated the facility provided each resident with a whistle, a flashlight, and there was emergency lighting in the hallways during the outage, which lasted approximately (2) hours, from 9:00 pm - 11:00 pm. The administrator stated all managers were notified and acted promptly, and all (3) residents using oxygen were handled appropriately. The incident report to the department did not document any concerns with the temperature changing and becoming hot/uncomfortable for the residents. Additionally, LPA contacted the local fire department and there was not an incident report made at the facility during the outage. The RSD indicated the facility conducts regular emergency drills, as required. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED-meaning although the allegation might have happened or is valid, the preponderance of evidence standards hasn’t been met. '*cont on 9099A-C-3.. 9099A-C-3.. Allegation: Staff are not meeting residents' bathing needs. The allegation states residents are not getting showers on schedule due to a shortage of staff on shift The administrator stated on 7/24/25 that the facility is "kind of restructuring the shower schedules" and requiring staff to document if the ADL was completed or not",using an Android phone. Interviews concluded that residents who have a scheduled shower on the "pm" shift feel they have to wait longer since there is less staff. One resident stated they "never miss a shower because I am demanding" but feels other residents may be if they don't demand one. The resident explained their showers are scheduled twice/week, on Wednesdays and Sundays and "staffing is always bad on Sundays between 2 pm- 6 pm, but PM the staff who are scheduled are "very good - the problem is there is just not enough staff". A second resident stated they don't miss showers but may refuse if they don't feel well. One staff stated they are "not sure about the "pm" shift- could be standby shower assistance needed, but indicated there are more staff in the "am" due to more showers being scheduled in the morning. Staff interviews revealed that there is a a part time staff to assist with showers on both the "am" and "pm" shifts. On 10/29/25, the administrator stated that (2) additional care staff were hired for weekend "pm" shifts three weeks ago. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED- meaning although the allegation might have happened or is valid, the preponderance of evidence standards hasn’t been met. Exit interview. Copy of report provided to the administrator. 9099C-4.. Several residents stated on October 24, 2025, the food temperature has improved over the last two weeks and the plates are now being warmed, which allows residents more time in eating their meal. A few residents stated they really like the breakfast choices but there are not low salt, diabetic options on the menu;however,the community does offer alternative options that change weekly. These options are for diabetics or anyone needing dietary accommodations. There were other concerns voiced by residents during interviews. One resident stated that they are "understaffed in the dining room with servers and with caregivers". This resident confirmed breakfast starts at 7:30 am and coffee is served starting then, off the cart, and believes there is "more training needed with the culinary staff as residents have to tell them a lot of details". A second resident stated the "ingredients are okay-there is a failure in assembling" the sandwich and gave the example that staff serve the mayo on the side instead of on the sandwich, which wasn't per their instructions. This resident stated breakfast is good, but the breakfast menu needs work as there is a "breakdown between the menu writer and the person who prepares the menu”. This resident stated, “staff need more training - newer people are less experienced”. Additionally, food is being served later with a longer wait time due to a "delay in following the menu", which could be an experience issue”. Multiple staff interviews indicated that they have heard residents complaining about the food being "cold a lot", a new lead Chef was recently hired, and many residents "don't have patience". Staff indicated there are "two servers currently and they need more servers" and explained that the other day, two residents got up and left after waiting 45 minutes for their food to be served. The administrator stated that the average service time is between 10-15 minutes for the entree and residents are starting with soup/salad. Meals are finished with desserts if desired. The administrator stated the steam tables stay on throughout the day and all food is tested for temperature prior to serving it. Also, food is ordered/delivered three days/week (M/W/F), so it shouldn't occur that the facility runs out of a particular food on a regular basis. Discussed personalized menu options. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (2) citations are issued on the 9099-D page. Exit interview with the administrator. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 29, 2025 · control 59-AS-20250721160041

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2) · Plan of correction due date: Nov 12, 2025

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement was not met as evidenced by: Based on interviews conducted, the Licensee did not ensure that resident (R1) received regular incontinent care, as scheduled, on October 24, 2025 (3:30 pm). LPA was speaking with (R1) at this time and was advised staff last provided continent care at 8:00 am that day, which posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Oct 29, 2025

Plan of correction: Licensee/Administrator agree to ensure that resident incontinent needs are met per each care plan. Additional staffing have been hired for weekends, specifically. Residents are being receptive to them already. Administrator to conduct an audit with the RSD to review residents with incontinence needs to ensure staff is providing the necessary care. Documentation due by 11/12/25 of the audit done.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(9) · Plan of correction due date: Nov 12, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement has not been met as evidenced by: Based on multiple interviews conducted, the LIcensee did not ensure that food was served at a temperature greater than room temperature/luke-warm, for an extended period of time, which posed a potential health and safety risk to residents in care. Many residents are still saying the food is served not warm enough to their preference.the state’s words, verbatim · CDSS document, Oct 29, 2025

Plan of correction: The Licensee/Administrator changed culinary procedures to plate food when it is individually ordered end of July 2025. Additionally, plates are being warmed prior to serving the food so it will stay warmer longer. Some residents are still finding the food is being served cold (i.e. pizza, waffles). The facility agrees to complete training with all culinary staff to continue to take into account each resident's individual preferences when taking/preparing the order. Training will be done with servers. Documentation due by 11/12/25 of the audit done. Food deliveries will continue to be M/W/F.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Parks arrived on Tuesday September 23, 2025, to conduct the unannounced annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (11) and staff (10) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. LPA and Administrator Cristina toured the facility together to ensure the health and safety of residents in care. The areas toured included the following areas in memory care and assisted living: resident apartments (9), resident bathrooms, common areas, kitchen, laundry room, and medication rooms. Facility had current inspection tags on fire extinguishers. Facility was current on fire drills. Water temperatures were within the required range. Facility had fully stocked first aid kits. All required postings were observed. Facility was clean and well organized. In the areas toured, there were no health or safety violations observed. LPA requested an updated LIC500, LIC610E, and current liability insurance by 9/30/2025. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Sep 23, 2025

Allegation investigated: Licensee is not ensuring that the facility has enough staff to meet the needs of residents in care. Licensee is not ensuring that the facility provides food services of the quality and in the quantity necessary to meet the needs of the residents in care.

On 12/12/2024 LPA Tryon visited the facility to complete the complaint. LPA met with Dana Stansel, ED. LPA interviewed 5 residents on this date. During the course of the investigation LPA has spoken with the Executive Director, 8 staff and 5 residents. LPA viewed food supplies, kitchen, dining room, viewed several meals, and toured facility. Regarding the allegation that Licensee is not ensuring that the facility has enough staff to meet the needs of residents in care, LPA toured the facility, spoke with 8 staff and 5 residents. Everyone interviewed felt that there are enough staff to meet resident needs. Sometimes staff may call in, but usually someone is called in to cover. Even on days that a replacement can't be found, it was felt that staff is still able to meet everyone's needs. Most said that response time to call buttons is usually no more than 10 minutes and usually way less time. No one mentioned any needs going unmet. Allegation is UNFOUNDED. Regarding the allegation that Licensee is not ensuring that the facility provides food services of the quality and in the quantity necessary to meet the needs of the residents in care: All residents interviewed enjoyed the food and all said there is plenty. Portions are generous, and all know that they can ask for more, Unfounded Regarding quality, all said the food is good. One person said it can be a little bland sometimes, but it is good and portions are good. All were aware that there are always at least 2 choices for main courses; and there is always the grill menu with burgers, hot dogs, sandwiches, etc. if they don't want either main course. All said they can always find something they like. Similarly, staff all believed the food was good and portions are generous. Many believed the portions are actually bigger then needed, as residents are often not able to finish the first portion given. Staff overall find the food good themselves, and most do eat meals from the facility kitchen. Staff are aware of certain person's special dietary needs, and the kitchen is always accommodating for those needs. LPA did not hear anyone say that the type of food is not healthy. Therefore, the allegation is UNFOUNDED. A finding of Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 59-AS-20241101163420

Type of visit: Required - 1 Year

On 8/28/2024 LPA Tryon visited the facility to conduct an annual inspection visit. LPA met with ED Dana Stansel. The facility currently has 91 residents, and approximately 96 staff. The facility consists of assisted living and memory care; and also has independent living apartments (not part of license). LPA toured the facility including both assisted living building and memory care. Memory care is in a separate building. We toured common areas, dining rooms, kitchen, laundry, medication room, resident apartments, bathrooms/showers, hallways, courtyards, storage areas, and storage for emergency food supplies. The facility is clean, spacious, nicely decorated, with plenty of space for various activities and outside areas for residents. Apartments are very spacious and nicely decorated. Bathrooms are clean, fixtures in good condition and functional. Facility has a fire alarm/sprinkler system that is checked/serviced regularly. Fire extinguishers present and charged. Facility has an infection control plan and is following protocol; has a good supply of PPE. LPA reviewed 9 of 91 resident files and 9 of 96 staff files. Files include required documents. LPA interviewed 2 residents and 2 staff. LPA reviewed the CARE Tool with Executive Director. At this time, facility appears to be in substantial compliance with regulations, no deficiencies were noted. Exit interview conducted.the state’s words, verbatim · CDSS document, Aug 28, 2024

Allegation investigated: Staff are serving a poor quality of food. Lack of supervision resulting in resident falling.

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegations listed above. LPA met with Administrator Dana Stansel during today's inspection. During the investigation LPA toured the facility, dining room, and kitchen. LPA observed 2-day perishable, 7-day non-perishable amount of food. LPA observed fresh fruits and vegetables being served to residents. LPA was present during a lunch serving, and food appeared to be warmed with a variety of food available to residents. In the kitchen the staff utilize warming trays and a heat lamp to ensure food stays warm during serving. LPA interviewed 5 residents and 7 staff members. Continuation on 9099-C. Unfounded Resident interviews indicated there is always a sufficient amount of food being served. There are fresh fruits and vegetables being served, and 4 of 5 residents indicate a variety of food choices available to residents. Resident interviews indicate at times the food will not be warm enough but staff will reheat food if requested. Staff interviews indicate that a variety of food is offered to residents, and fruits and vegetables are always available. Staff interviews indicate they have heard complaints about the temperature of the food, but they are always available to reheat if needed. Due to the information gathered, LPA finds allegation to be UNFOUNDED. LPA investigated allegation, "Lack of supervision resulting in resident falling". Relevant party indicated there is a lack of staff available to residents in need. Relevant party indicated that a resident had a fall during the day hours and staff responded quickly. Relevant party had concerns if the fall occurred during the night hours if the staff would have been able to respond quickly. LPA interviewed 5 residents and 5 care staff. Of the 5 residents interviewed, they required care and supervision. Residents stated they have had no falls due to a lack of supervision. LPA interviewed staff in which they all stated they are not aware of any resident having a fall due to a lack of supervision. Staff indicated they have sufficient staff to meet the needs of the residents in care. Due to the information gathered, LPA finds allegation 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. Exit interview conducted. 2 of 5 residents indicated they have observed residents waiting for care when needing escorts back to their rooms. Residents interviewed stated there is enough staff available to meet their care needs. Staff interviews indicated they have sufficient care staff to meet resident needs. Staff stated they work as a team and if caregivers are performing care and a resident needs help, a med tech or manager will check on the resident. Staff stated at times they have call offs but they are able to meet the needs of the residents. Staff stated that residents can get a hold of them by pushing a pendant, calling the front desk by using the "Alexa" in their room, or by using their pull cord for emergencies. Due to the information gathered, LPA finds allegation to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 59-AS-20240502101513