Atria San Juan.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Executive Director/Administrator (ED) James Craddock and explained the reason for the visit. James Craddock's Administrator's Certificate expires on November 8, 2026. Facility is licensed for 140 non-ambulatory residents with a hospice waiver for 10. The facility is composed of two buildings connected by a hallway. The main building (building B) is 3 stories and houses the memory care unit on the second floor. The secondary building (building A) is two stories. Building B has an interior outdoor courtyard with a water fountain. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA and ED toured the facility. LPA observed the kitchen and dining room are clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Emergency food and water are stored in a storage room next to the kitchen. LPA observed a 3 day emergency supply of food and water. LPA observed the TV/Library room on the first floor. There is a large screen TV, books and magazines and games for residents. LPA and ED toured 10 resident rooms. All 10 resident rooms had the required furnishings. All rooms inspected had clean and operational bathrooms. Hot water measured 108.8 degrees Fahrenheit to 118.0 degrees Fahrenheit in all 10 bathrooms inspected. LPA observed all the fire extinguishers throughout the facility are fully charged. The facility has 4 stairways, 2 in each building. LPA observed and emergency evacuation chair at each stairway. The last emergency drill was conducted on April 9, 2026. LPA observed medication is kept locked in a cart in the medication room. The first aid kit in the medication room has all the required elements. LPA and the Executive Director toured the second floor memory care. LPA tested the delayed egress doors in memory care unit. Both delayed egress doors tested operational. LPA observed shaded outdoor seating next to the dining room and in the interior courtyard. No obstacles or hazards observed inside or outside of the facility. During the visit LPA observed residents participating in card games in the TV/Library room. 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 There is a computer with internet access in the TV/Library room that is dedicated for resident use. LPA interviewed 4 staff and 4 residents. LPA reviewed 7 staff files. All staff are background cleared and associated to the facility. All staff files reviewed had the required training. LPA verified that there is staff on each shift that have CPR training. No discrepancies observed in the staff files. LPA reviewed 10 resident records and medications. No deficiencies are being cited as a result of this visit. An exit interview was conducted with the Executive Director and a copy of the report provided.

out of 4 staff interviewed reported they call 911 if required and 911 is not called for lift assistance. LPA contacted the Orange County Fire Authority but the First responders who responded to the calls were not available for interview. The Administrator reported that in memory care 911 is called in case of head injury that the resident may not be able to report. Both incidents listed above took place in memory care. 4 out of 4 staff interviewed reported that they would assist residents off the floor after a fall if there are no injuries and no signs of head injury and the resident is not in pain. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.

In memory care staff were assisting residents with playing individual card games while other residents were listening to music. The Executive Director and the Activities Director reported that activities are always provided but many residents choose not to participate, which makes it very challenging for staff. 3 out of 4 residents interviewed reported that they have participated in activities at the facility. Based on the evidence gathered the allegation, is unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff did not safeguard resident’s personal items, revealed the following. It was reported that Resident 1 (R1) had their phone taken from them. The Administrator reported that R1’s responsible party refused to have R1’s items inventoried. The Administrator stated that they do not know what items R1 moved in with. Staff 1 (S1) reported that R1’s phone was found outside of their room, so they contacted R1’s responsible party and informed them. S1 reported that they didn’t think R1 could use the phone, so they contacted the responsible party. S1 reported that nothing was done to the phone, and it was given to R1’s responsible party in the condition it was found. R1’s responsible party stated that staff did give the phone back but there were new applications on the phone. R1’s responsible party would not answer any further questions during the investigation. 4 out of 4 staff interviewed reported that when residents’ belongings are found they are turned into lost and found until someone claims them. S1 reported that residents in memory care misplace or lose items, and they give it back to the resident or contact the responsible party. No other items were reported missing. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, Resident is not accorded privacy during visits, revealed the following. It was reported that during visits with R1 the family was not given privacy and visits were only allowed in the resident's room 2 times. At the time of the report, visits were allowed at facilities as long as Covid-19 precautions were implemented such as social distancing and wearing masks as outlined in PIN 21-17.1-ASC dated April 23, 2021 and PIN 21-17.2-ASC dated May 14, 2021. The Executive Director reported that all visitors are given privacy and had the choice of visiting in residents’ rooms, in the common areas or outside. 4 out of 4 staff interviewed reported that none of the visitors were denied access to residents' rooms or denied privacy on visits. R1’s responsible party did not answer any questions regarding visitation. 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 4 our of 4 residents interviewed reported they have always been given privacy during their visits. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, resident was malnourished while in care, revealed the following. It was reported that R1 lost 18 pounds during their stay at the facility and was not fed properly. 4 out of 4 staff interviewed reported that Resident 1 (R1) ate and had no issues with food. The Executive Director reported that R1’s responsible party requested meal logs showing R1 was eating and they were provided. A review of the records shows R1 ate breakfast lunch and dinner during their time at the facility from May 1, 2021 to May 18, 2021. On May 19, 2021 R1’s responsible party had R1 sent to Newport Bay Hospital. R1’s physician’s report showed R1 weighed 200 lbs. on April 5, 2021. Newport Bay Hospital closed on February 22, 2023 so no records are available to compare R1’s weight. R1’s where abouts are unknown. No evidence was gathered to support the allegation, therefore the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Executive Director (ED) James Craddock and explained the reason for the visit. James Craddock's Administrator's Certificate expires on November 8, 2026. Facility is licensed for 140 non-ambulatory residents with a hospice waiver for 10. The facility is composed of two buildings connected by a hallway. The main building (building B) is 3 stories and houses the memory care unit on the second floor. The secondary building (building A) is two stories. Building B has an interior outdoor courtyard with a water fountain. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA and ED toured the facility. LPA observed the kitchen and dining room are clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Emergency food and water are stored in a storage room next to the kitchen. LPA observed the TV/Library room on the first floor. There is a large screen TV, books and magazines and games for residents. LPA and ED toured 9 resident rooms. All 9 resident rooms had the required furnishings. All rooms inspected had clean and operational bathrooms. Hot water measured 105.0 degrees Fahrenheit to 120.2 degrees Fahrenheit in all 9 bathrooms inspected. LPA observed all the fire extinguishers throughout the facility are fully charged. The facility has 4 stairways. LPA observed and emergency evacuation chair at each stairway. The last fire drill was conducted on April 15, 2025. LPA observed medication is kept locked in a cart in the medication room. The first aid kit in the medication room has all the required elements. LPA and the Executive Director toured the second floor memory care. . LPA tested the delayed egress doors in memory care unit. Both delayed egress doors tested operational. 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 observed shaded outdoor seating next to the dining room and in the interior courtyard. No obstacles or hazards observed inside or outside of the facility. During the visit LPA observed residents participating in a trivia activity in the TV/Library room. There is a computer with internet access in the TV/Library room that is dedicated for resident use. LPA interviewed 4 staff and 4 residents. LPA reviewed 6 staff files. All staff are background cleared and associated to the facility. All staff files reviewed had the required training. No discrepancies observed in the staff files. LPA reviewed 9 resident records and medications, no discrepancies were observed. No deficiencies are being cited as a result of this visit. An exit interview was conducted with the Executive Director and a copy of the report provided.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Executive Director James Craddock, who's Administrator's certificate expires on November 8,2024, and explained the reason for the visit. LPA and the Executive Director toured the facility. The facility is composed of two buildings connected by a hallway. The main building (building B) is 3 stories and houses the memory care unit on the second floor. The secondary building (building A) is two stories. Building B has an interior outdoor courtyard with a water fountain. LPA observed the PUB 475 poster (See Something, Say Something) is posted in the main entrance of the facility. LPA observed during the tour that all 4 stairways had emergency evacuation chairs. LPA observed each floor of each building had a working carbon monoxide detector. LPA observed all fire extinguishers are fully charged. LPA observed that the smoke detectors in all 10 rooms that were inspected were operational. LPA measured the hot water in rooms inspected. Hot water measured between 109.0 degrees Fahrenheit to 112.6 degrees Fahrenheit. LPA observed all resident rooms had the required furnishings. LPA observed the fireplace in the resident library is screened. LPA and the Executive Director toured the dining room and kitchen. LPA observed a 2-day perishable and a 7-day nonperishable food supply on hand in the kitchen. LPA observed the kitchen is clean and organized. LPA observed the emergency food stored in a supply closet and the emergency water supply is stored in a storage room. LPA and the Executive Director toured the second floor memory care. LPA observed the medication cart is locked and kept in the life guidance med room. LPA tested the delayed egress doors in memory care unit. Both delayed egress doors tested operational. LPA observed shaded outdoor seating next to the dining room and in the interior courtyard. No obstacles or hazards observed inside or outside of the facility. During the visit LPA observed residents participating in bingo in the activity room. LPA interviewed 6 staff and 7 residents. LPA reviewed 6 staff files. All staff files reviewed had the required training. No discrepancies observed in the staff files. LPA reviewed 7 resident records and medications, no discrepancies were observed. The last fire drill was conducted on May 13, 2024. LPA consulted with the Executive Director regarding reporting requirements. No deficiencies are being cited as a result of this visit. An exit interview was conducted with Executive Director and a copy of the report provided. 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 consulted with the Executive Director regarding reporting requirements. No deficiencies are being cited as a result of this visit. An exit interview was conducted with Executive Director and a copy of the report provided