Atria Rancho Mirage

Allegation #1: Staff are not trained to dispense medication. The complaint alleged that when a med tech calls out, untrained caregivers dispense medication to residents. On November 20, 2025, the Licensing Program Analyst (LPA) Richard interviewed the Administrator (A1), who denied the allegation and stated that the staff who assisted the residents with medication had been trained and held certificates to assist with medication. The LPA interviewed two Med Techs (MT1, MT2), who denied the allegation and stated that all the staff who assist the residents with medication are properly trained. They also noted that the caregivers do not have access to the Medication Carts. Additionally, the LPA interviewed four staff members (S1-S4), all of whom denied the allegation and asserted that they have not been trained and have not dispensed any medications to residents. Their duty is caregiving; only Med Techs give medications. The LPA also interviewed eight residents (R1-R8), all of whom expressed satisfaction with how the facility's staff administers their medications and stated that they have no issues with them. There is no specified time when a caregiver provides them with their medications. Furthermore, on November 20, 2025, the LPA reviewed the facility training medication documents from 2023, 2024, and 2025 for all Med Tech members who assist residents with their medications. Report Continued on LIC9099C 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 the interview, the records, and the information reviewed, there was insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is deemed unsubstantiated. Allegation #2: Staff are mismanaging residents' medication . The complaint alleged that staff members are mismanaging residents' medications, resulting in numerous errors that lead residents to refuse their medications. On November 20, 2025, LPA Richard interviewed A1, who denied the allegations and stated that only Med Techs assist with and manage the residents' medications. The LPA also interviewed two Med Techs (MT1 and MT2), who both denied the allegations. They stated that they follow the procedures outlined in the facility's internal training, which occurred from October 3, 2024, to September 14, 2025. They explained that if a resident refuses their medication, the Med Tech records it in the electronic medication administration record (E-Mar), contacts the family member and the physician, and disposes of the medication. Additionally, if medication is spilled by either staff or residents, they must contact the pharmacy to obtain a replacement and document this action in the E-Mar. Report Continued On LIC9099C 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 On November 20, 2025, the LPA interviewed eight residents (R1-R8). Of these, five residents denied any issues with medication management. The caregiver never gave them any medication except Med Tech. On the same day, the LPA reviewed the MAR records of eight residents from 2025 and found no discrepancies in their medications. The LPA also reviewed the Med Techs' medication training, and all had completed it. The MT1 also explained to LPA how the processes of refused and/or spilled medications work. Based on the interview, the records, and the information reviewed, there was insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is deemed unsubstantiated. Allegation #3: Staff are not keeping accurate records of medication distribution. The complaint alleged that staff were backdating and forging their names on the residents' electronic Medication Administration Records (e-MAR) and on the hard-copy log for narcotics. On November 20, 2025, at 11:30 a.m., LPA Richard, Med Tech Martinez, and Santana inspected the medication room to review the resident supply and the medication cart. Upon examining a randomly selected resident's medication supply and records, LPA found the medication record to be accurate. Report Continued on LIC9099C 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 The information documented in the electronic record matched the number of pills dispensed to the residents. Additionally, LPA reviewed the residents' medication records and found that all were signed on the day the medications were administered. Based on the interview, the records, and the information reviewed, there was insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is deemed unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the administrator, Nathan Boese.

Licensing Program Analyst (LPA) Seo Jeon and Janira Arreola conducted an unannounced annual required visit. Upon entry, LPA was greeted by Nathan Boese, Executive Director, and informed them of the purpose of the visit. At the time of the visit, there were (17) staff members and (113) residents present. Facility Overview: The facility is a two story building with (110) bedrooms and (126) bathrooms. Second floor is designated for memory care unit. The facility has fenced swimming pool and a hot tub. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility has infection control plan in file. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. Hot water temperature was 106°F. LPA reviewed annual inspection report conducted by fire marshal dated January 8, 2025 with passing inspection. Fire extinguishers located at hallways have current inspection tags. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Continued 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 Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Record Review and Resident/Staff Files: LPA reviewed files for four staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Five resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked in a medication room. LPA reviewed medications for four (4) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on September 22, 2025, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.

Licensing Program Analysts (LPAs) Yolanda Delgado and Armando Perez arrived unannounced to conduct an annual inspection. Upon arrival LPAs was greeted by facility staff and granted entry. LPAs began inspection with introduction, visit purpose and provided the facility with LPA identification and business card. Resident record review began- Six (6) records were reviewed. LPAs reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Physical Plant and Safety of Environment/Operational Requirements- LPAs toured the facility inside and outside. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 109.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. A medication room is provided for medications and sharp objects. LPAs verified there is a telephone working at this location. Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. LPA began review of employee records- Six (6) records were reviewed. LPAs reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. (Continued on next page) 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 (Continued on from page 1) The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current. LPAs made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 12/8/2023. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 09/18/2024. LPA allocated time to prepare this report for delivery. Based on the information received during this visit today, there are no deficiency is being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with and a copy provided to the facility representative provided at the time of the exit interview.

Therefore based on interviews and record review, the allegation “Staff will not change resident’s diaper” has been deemed UNSUBTATIANED at this time. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of this report was provided to Executive Director Monique Moreira.

Licensing Program Analyst (LPA) Crystal Colvin arrived unannounced to conduct a case management visit to obtain signatures for an amended case management report deficiency page dated 1/12/23. LPA met with Executive Director Monique Moreira and advised them of the purpose of today’s visit. No other citations were noted on today's visit. An exit interview was conducted with Executive Director Monique Moreira and a copy of this report and amended LIC809D from 1/12/23 was provided.

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that one-hundred twenty-five (125) residents live at this facility. There are twenty-six (26) staff members present. The Administrator, Monique Moreira conducted the tour. The Business Director, Sandra Zendejas completed the tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Five (5) record were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. (Continued on LIC809C) 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 (Continuation from LIC809) Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen. Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 78 degrees for the resident’s comfort. Lighting is sufficient for safety. Water temperature measured at 108.0 degrees F. Laundry is done in the designated laundry room on the first floor. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There is not a fireplace at this facility. There is a gated pool at the facility, that is surrounded by a 5-foot gate and latch. The facility had their last annual fire inspection by Fire Master on 11/16/2022. LPA reviewed the facility’s last disaster drills, which met the department's requirements. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. (Continued on LIC809C) 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 (Continuation from LIC809) Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked pushcart allocated for medication storage in the Medication Room. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed if they were dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The fire extinguishers throughout the facility were last serviced and tagged on 11/22/22. According to the fire inspection, there are nineteen (19) fire extinguishers throughout the facility. Pursuant to the Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to the Business Manager, Sandra Zendejas.

allegation is deemed UNSUBSTANTIATED at this time. It was also alleged facility staff failed to provide R1 with planned activities. Staff interviews revealed R1 was encouraged to come out of their bedroom to participate in activities; however, the resident refused to leave their room. An interview was attempted with R1, however, they declined to answer any questions. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. Lastly, it was alleged facility staff did not ensure R1's care needs were met while in care. It was reported R1 was left in the same clothing worn the day prior, and not assisted to change. Staff interviews revealed R1 was assisted to change partially, however, declined further assistance from staff on or around April 04, 2023. R1 declined to be interviewed. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. This report was reviewed with Moreira and a copy was provided.

On March 17, 2023, Licensing Program Analysts (LPAs) Chinwe Nwogene and Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit regarding an eviction process taking place. During the visit, staff and resident were interviewed, resident file and facility record was reviewed to make sure the eviction process is in compliance with Title 22, California Code of Regulations. No deficiencies noted at the time of visit. An exit interview was conducted, and a copy of this report was reviewed with and provided to Monique Moreira.

An office meeting was held on this date with Deborah Mullen, Licensing Program Manager, Jesse Gardner, Licensing Program Analyst, and Nicole Wentworth, Regional Vice President. The meeting was to discuss the current management team in place at Gladwell Rancho Mirage. During the meeting it was confirmed that the managing members identified on the Administrative Organization form submitted June 26, 2019 are still current. Wentworth was asked to submit a current Personnel Report (LIC500) to the office by January 27, 2023. Wentworth was given LPA Stephanie Torres' contact information who is the current assigned LPA. An exit interview was conducted and a copy of this report was reviewed with and provided to Nicole Wentworth.

Allegation #2 “Facility does not have adequate staffing to meet the needs of the residents”. LPA interviews with facility staff revealed that the facility has enough staff to meet the client's needs. LPA interviews with clients revealed that the clients could not remember if there was enough staff working at the facility in July 2020. Investigation into this incident reveals insufficient evidence to corroborate the allegation. Allegation #3 “Facility is not providing food of the quality and quantity to meet the resident's needs”. The allegation alleges that the food is not of good quality. The allegation further alleges that the bread is stale, the eggs are powdered, and the food is terrible. LPA interviews with staff revealed that the clients are provided food of good quality and quantity. LPA interviews with clients revealed that the clients could not remember the quality and quantity of food in July 2020. LPA file reviews revealed that the facility contracts with Crandall Dietitian Services which creates the facility’s food menus. Investigation into this incident reveals insufficient evidence to corroborate the allegation. Allegation #4 “Staff are not properly trained”. The allegation alleges that the facility’s staff are not properly trained to do transfers. LPA file reviews of staff training records revealed that facility’s staff were properly trained. Based on the investigation, the above findings are Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to conduct a case management visit to follow up on information that the Department needed. LPA met with Business Director Sandra Zendejas and toured the facility. LPA advised Zendejas that an updated LIC500 is needed by CCL and to provide to LPA by January 17, 2023. Upon review of the facility roster found in Guardian, LPA noted that Assistant Executive Director (Interim Administrator) April Princesa was not associated to Gladwell Rancho Mirage. Princesa began employment in mid November, 2022, and is at the facility on Tuesday, and Wednesday's, and some weeks it rotates to Wednesday, Thursday's. Princesa was not on property at the time of visit. Deficiency was cited per Title 22. No other citations were noted on today's visit. An exit interview was conducted where a copy of this report was discussed and provided along with the LIC809-D, LIC421-BG, and Appeal Rights.

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Community Business Director Sandra Zendeias, and Administrator Monique Moreira (via telephone) and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. LPA Colvin did not conduct a tour of the community, as the facility has an active COVID-19 outbreak at this time. Below is a summary of inspection: Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Community Business Director Sandra Zendeias, and reviewed the facility's Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels, and hand washing guides are posted. Upon entering the facility, LPA Colvin observed postings for cough etiquette, social distancing, and infection control. Community Business Director Sandra Zendeias and Administrator confirmed plenty of PPE supplies (such as masks, gowns, gloves). LPA Colvin went over the various recommended training for facility staff with Community Business Director Sandra Zendeias in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. Community Business Director Sandra Zendeias confirmed that all staff have been fit tested, and that they will be re-fit tested annually. LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Community Business Director Sandra Zendeias confirmed that staff are continuing to monitor residents’ symptoms, and that both staff and visitors are screened for COVID-19 symptoms prior to entering the facility, which LPA Colvin confirmed through being screened upon entry as well. LPAs Colvin additionally observed a sign-in log for visitors, where their temperature is recorded as well as answers to screening questions. Administrator stated New Administrator Packet was previously sent to Licensing. LPA Colvin to follow up. An exit interview was conducted with Community Business Director Sandra Zendeias and a copy of this report was provided.

Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA Gardner met with Executive Director Jonathan Karp. Present in the facility during time of visit were forty-eight (48) staff as well as eighty-nine (89) clients. There are currently no cases of COVID-19 within the facility. During today's visit, LPA Gardner toured the facility and made observations pertaining to the facility's infection control measures. LPA Gardner observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. During the inspection LPA Gardner discussed infection control practices and procedures with Mr. Karp. An exit interview was conducted and a copy of this report, was reviewed with and provided to Mr. Karp.

Based on the aforementioned, there is not enough available evidence to corroborate or refute the allegation. We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and a copy is being furnished to Executive Director Jonathan Karp.