Atria Carmichael Oaks

LPA interviewed care staff in which they stated R1’s appetite began to decline while on hospice care but R1 was still able to eat finger foods and staff continuously offered food. Due to the information gathered LPA finds allegation to be Unsubstantiated. LPA investigated allegation, “Staff did not assist resident with obtaining medical care”. LPA interviewed relevant parties and staff and reviewed resident medical documentation and facility documentation. LPA interviewed relevant party in which they stated R1 was on hospice care but R1 was declining rapidly due to an untreated Urinary Tract Infection(UTI). Relevant Party stated once R1 was moved, new care staff observed signs of an UTI and R1 was treated and began to regain their strength. LPA interviewed care staff in which they stated they did not observe any signs of an UTI. Care staff stated they changed R1 every 2 hours or as needed. LPA interviewed hospice staff in which they stated they had no concerns with R1 receiving proper continence care. Hospice staff stated once R1 did move, new facility staff did report signs of a UTI and antibiotics were provided to R1 to resolve the issue. LPA reviewed hospice documentation, and found no concerns related to an UTI or continence care. LPA reviewed facility documentation, and found no concerns or documentation concerning continence care or an UTI. Due to the information gathered, LPA finds allegation to be Unsubstantiated. LPA investigated allegation, “Staff did not assist resident with ambulating”. LPA interviewed relevant parties and staff and reviewed resident medical documentation and facility documentation. LPA interviewed relevant party in which R1 began needing more caregiver assistance toward the end of their stay and staff would not help R1 out of bed and R1 became bedbound. Relevant party stated that once R1 moved out of the facility and received treatment for an UTI, R1 was no longer bedbound. LPA interviewed care staff in which they stated R1 was ambulatory and walking around facility until August 2025 while on hospice care. Continuation on 9099-C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 R1’s health was declining and by September 2025 R1 was unsafe to ambulate independently and was bedbound. Caregiver stated they would try to get R1 out of bed but R1 was too weak to be moved into a wheelchair. R1 moved out of the facility on September 17 th . LPA interviewed hospice staff in which they stated facility staff were assisting R1 with ambulating until September 2025 when R1 was needing more assistance to transfer and the facility had limitations with providing a lift assist. Hospice staff stated R1 needed a higher level of care and was moved shortly after. LPA reviewed facility documentation in which resident was ambulating in and out of bed until September 2 nd , and a care conference was scheduled with responsible parties concerning R1’s decline. LPA reviewed hospice documentation, and there was no documentation showing facility staff were not assisting resident with ambulation. Due to the information gathered, LPA finds allegation to be unsubstantiated. LPA investigated allegation, “Staff did not communicate with responsible party regarding resident's care”. LPA interviewed relevant parties and staff and reviewed resident medical documentation and facility documentation. Relevant party stated facility staff would not communicate with R1’s responsible party regarding resident’s care and billing. LPA interviewed care staff and memory care manager in which they stated they spoke to R1’s responsible party several times a week and had a care conference with responsible party prior to R1’s move out. Memory care manager provided LPA emails and text messages to and from R1’s responsible party showing communication. LPA interviewed hospice staff in which they stated a care conference was held on 9/4/25 with facility staff, hospice, and responsible party over the phone concerning R1’s health concerns. Hospice staff stated they scheduled another in-person meeting with responsible party and no one from the facility showed up. Due to the information gathered LPA finds allegation to be Unsubstantiated. Continuation on 9099-C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA investigated allegation, " Staff are charging resident for care not rendered". LPA interviewed relevant parties and administrator and reviewed documentation. R1 was placed on hospice in June 2025 and their rates increased. Relevant party stated they were charged for services that were not rendered from facility staff and therefore the responsible party should be reimbursed for that. LPA interviewed administrator in which she stated once R1 moved out of the facility the responsible party requested for a refund. Normally facility requires a 30-day notice during the move out process but administrator stopped the fees on 9/17/25, the day R1 moved out. No further refund was issued. LPA interviewed staff in which they stated they provided proper care to R1. LPA interviewed hospice staff in which they stated there were no concerns about neglect but R1 needed to move out to higher level of care. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted and copy of report provided.

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

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

Allegation: Staff financially abused a resident. The allegation regarding financial abuse was investigated at the El Camino Gardens location. The findings were delivered on 5/4/2023 and were Unsubstantiated. The Department conducted records review and interviews. On 3/17/2023, the ED indicated that money removed from R1's account was from an auto payment that R1 had signed up for during admission to the facility. Interview with R1 indicated that they had requested a stop to the auto payments, however, facility continued with auto payments. The complaint is also regarding overcharging, which was investigated at the El Camino Gardens location. The findings were delivered on 3/24/2023 and were Unsubstantiated. The Department conducted a records review of R1's admission agreement and invoices itemizing charges from October 2022-March 2023. R1's admission agreement signed 10/27/2022 states "If you become a safety risk to yourself or to others during your residency, we have the right in our sole determination to obtain, at your expense, private duty personnel to provide supervision or assistance until you move from the Community or your safety is no longer at risk." According to interview with ED, the facility began providing R1 with additional supervision ensuring R1's safety after a suicide attempt that occurred on 1/1/2023. R1 was charged due to the change in condition. Allegation: Staff mishandled a resident's medical form. The allegation regarding mishandled medical form was investigated at the El Camino Gardens locations. The findings were delivered on 5/4/2023 and were Unsubstantiated. The Department conducted record review and interviews to investigate this allegation. Interview with R1 indicated that they believe the facility intentionally altered their Physician Report LIC602A in order to increase R1's rent. Interview with ED conducted on 3/17/2023 indicated that a new LIC602A was faxed to the facility by R1's primary care physician (PCP) after ED expressed concerns to R1's PCP regarding R1's medications. Record review indicated that R1 signed an Authorization to Release Health Information form which permits the facility to contact R1's PCP for medical purposes. Records review also indicated that R1 has had five (5) LIC602As since October 2022. Due to the information provided that R1 has never resided at the Carmichael Oaks location and that the allegations have already been investigated at the El Camino Gardens location, the above allegations are 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 and a copy of this report was provided to the facility.

On 7/22/2022, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a required annual. LPA met with Barbara Fleck, Executive Director, and explained purpose of the inspection. Before today's inspection, LPA completed required COVID-19 testing protocols and completed daily assessment. LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. The facility is licensed for (95) residents and has a hospice waiver for (15). There are (1) residents currently on hospice. There are (19) residents in memory care unit, the facility is licensed for (20). LPA and Executive Director toured the interior of the facility including the Assisted Living Unit, Memory Care Unit, laundry, library, staff break room, restrooms, salon, and common areas including the lobby area. In areas toured, LPA observed the facility to be clean, safe and in good repair and to not pose a health and safety risk or personal rights violation. LPA observed paper towels, soap and trash cans with a lid. Inside temperature was observed to be 73* F. LPA toured the kitchen and observed 2+ day perishable and 7+ day nonperishable food. LPA observed the Administrator Certificate posted (Barbara Fleck #6041744740) to be expired 7/21/2022. Executive Director provided proof of renewal to LPA, mailed to CDSS on 5/23/2022. LPA observed the fire extinguishers to be last serviced 1/18/2022. LPA requested an copy current liability insurance during today's inspection by Friday 7/29/2022. There were no deficiencies observed during today's inspection. Exit interview. Copy of report left at facility with Executive Director.

Licensing Program Analyst (LPA) Sabrina Calzada and Regional Manager (RM), Alycia Berryman arrived announced to participate in a scheduled inspection with the Healthcare-Associated Infections (HAI) Program. LPA and RM met with Kristy Trausch, CII and Sheila Gonzaga, Sacramento County Public Health, Barbara Fleck, Administrator and a facility corporate staff member. LPA and RM met the other participants in the facility lobby and were advised the inspection scheduled at 8:30 am had just finished. LPA and RM explained they had to be tested and cleared in the regional office prior to arriving on site. Additionally, LPA and RM completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): N95 mask. Kristy Trausch, CII stated that she found the facility to be practicing effective Covid-19 infection prevention protocols and suggested that facility staff increase disinfection and change masks when appropriate. LPA provided multiple PPE supplies to the facility at the conclusion of today's inspection. There are no deficiencies issued during today's inspection. This report was emailed to the facility Administrator on 4/20/2022 for signature.

Licensing Program Analyst (LPA) Williams arrived at the facility unannounced on 07/26/2021 to conduct a Required 1- Year Inspection utilizing the infection control domain. LPA met with Administrator, Kimberly Hagen, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA was screened by facility staff upon entering the facility. LPA and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and administrator completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report left at the facility.