Atria Golden Creek

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.

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. T he 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.

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) 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 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.

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.

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.

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.

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 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 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.

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.

Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced case management visit to follow up on an incident report dated 12/08/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit to Executive Director James Craddock. Unusual Incident/Injury Report (LIC 624) was received on 12/08/2022 for an incident that occurred on 12/08/2022. Per LIC 624 Resident 1 (R1) advised medtech they took incorrect dosage. Medtech called 911 and paramedics came to assess R1. R1 was then transferred hospital and admitted overnight, R1 returned on 12/09/2022 without new orders. Per interview with Staff 1 (S1) noticed that R1 did not appear well. R1 told S1 that they believe they took double dosage of self - administered medication. S1 then called 911 to have R1 assessed. Review of LIC 602 indicates R1 cannot administer own medications but doctors orders dated 09/26/2022 state R1 can self administer 1 medication. During the visit LPA reviewed LIC 602 and Doctors Orders dated 09/26/2022. No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.

Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year Annual inspection, with an emphasis on Infection Control due to the COVID-19 pandemic. LPA Martinez was screened upon entry into the facility. LPA met with Executive Director James Craddock and reason for the visit was explained. ED Craddock confirmed there are currently no cases or exposures of COVID-19 within the facility. ED Craddock's Administrator Certificate expires on 11/8/2022. LPA toured the facility with ED Craddock. Facility has 108 Residents in care during today's visit with 12 Residents receiving Hospice care. Facility consists of Assisted Living with a Memory Care on the 1st floor. LPA observed Fitness Room, Salon/Spa, Multi-Use/Activity Room, Theater, Bistro, Dining Room, Kitchen, and a private Dining Room on the first floor; the Library on the 2nd floor, and Art Studio and a Sky Lounge on the 3rd Floor. LPA observed Residents relaxing, walking around and/or having lunch. Residents appeared happy and well taken care of. Facility appears clean and sanitary. Resident rooms have the required elements as well as common bathrooms were stocked with soap, sanitizer and paper towels. Rooms are single occupancy in Assisted Living and Memory Care. Visitors are screened using a questionnaire. LPA observed the screening/sanitizing station at the entrance of the facility. Facility does temperature check and has a sign-in log sheet. Facility takes resident and staff temperatures daily and documents. First Aid kit has all required items. Mitigation Plan has been approved. Facility has emergency evacuation chairs at the top of stairwells. LPA observed an ample supply of emergency food and water. LPA observed outside visitation area. LPA observed the Medication Room and facility uses electronic medical records for medication management. Facility has a plan for COVID testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed select resident files during the visit and files are up to date including emergency information. Most residents and staff are vaccinated for COVID-19. All required Department poster were observed. No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report will be emailed to ED.