Inspection Reports for
Atria El Camino Gardens

The facility was found deficient in ensuring resident rights during an eviction process involving a resident with dementia, failure to notify the licensing agency of a hospitalization incident, and issues related to eviction notices containing intimidating language. Deficiencies were cited as Type B, indicating potential risks to health, safety, and personal rights of residents.

The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis.

The investigation found the allegations to be unfounded based on interviews and documentation reviewed, including the eviction notice which provided alternative housing options and confirmation that toilet paper was supplied to the resident as needed. No deficiencies were cited.

The inspection found the facility to be in compliance with all applicable regulations. No deficiencies were cited. The facility was observed to be properly maintained, with safe food storage, medication security, and operational safety equipment.

The visit was triggered by an incident report (LIC624) concerning a resident who was missing from their apartment on March 22, 2025. The resident was found walking outside and was evaluated by emergency medical services. The resident's responsible person provided 1:1 care and later reported hospital admission unrelated to the incident. The complaint was not substantiated with any citations.

The resident was found safe after being missing for a short period, exhibited agitation and paranoia, but showed clear cognition upon evaluation. The resident was later admitted to the hospital for reasons unrelated to the incident. No citations were issued in this report.

No deficiencies were observed during the visit. The Licensing Program Analyst and Executive Director discussed the closure of the death report, noting that the resident was found unresponsive during a meal check and had a POLST with 'do not resuscitate'.

The facility was found to be clean, sanitary, and maintained at a comfortable temperature. No deficiencies were cited during the inspection, though sharps were observed in one resident's room and the policy on residents storing detergents is under review.

The visit was triggered by a death report complaint received on 09/19/2024. The incident remains under review with no substantiation status provided.

Licensing Program Analysts met with the Executive Director and conducted a file review of the resident's records. The incident is still under review by the Department.

The Licensing Program Analyst observed the facility to be clean, safe, sanitary, and in good repair, with compliance to the Stipulation and Waiver and Order. Facility audits, emergency call responses, care records, incident reports, and staff training were reviewed and found satisfactory.

The facility was observed to be clean, safe, sanitary, and in good repair. The Licensing Program Analyst reviewed audits of staff hours, emergency call responses, incident reports, and staff training documentation. The facility was found to be in compliance with the Stipulation and Waiver and Order.

No deficiencies were observed during the visit. A family visitation dispute was discussed and the facility was advised to document and report any future incidents.

LPAs discussed serious/unusual incident reports related to emotional distress and medication storage incidents. The facility was reminded of timely reporting requirements and medication protocols. A death report was reviewed, with cause of death unknown as the resident had not been at the facility for weeks. No deficiencies were cited during this visit.

The facility was toured and observed to be in compliance with no violations of health, safety, or personal rights. The CARE tool was completed and no deficiencies were found.

The facility failed to provide a written notice within two business days to a resident regarding a change in level of care and the implementation of new private duty personnel services, which is a violation of Health and Safety Code §1569.657(a).

The facility was found to be in substantial compliance with infection control requirements. No immediate health, safety, or personal rights violations were observed and no deficiencies were cited.

The Licensing Program Analyst observed that the facility was clean and in good repair, alert button logs were documented and responded to timely, resident care tasks and staff numbers were sufficient, and monthly staff training was conducted with attendance documented. No deficiencies were cited during this visit.

The visit was triggered by complaint #25-AS-20220426122233. The complaint involved review of the 'Secured Environment Addendum' for resident (R1), which was signed by the resident's Power of Attorney rather than the resident. The complaint was substantiated by this finding.

The facility was cited for failing to ensure that a resident signed the 'Secured Environment Addendum'; instead, the document was signed by the resident's Power of Attorney, which posed a potential personal rights violation. This deficiency was previously cited in 2018.

The visit was triggered by multiple incident reports (LIC624) concerning resident falls and behavioral concerns. The incidents were discussed individually, and no deficiencies were found.

The inspection reviewed incidents involving four residents who experienced falls or behavioral issues. No deficiencies were cited during the inspection.

No violations were cited during this visit. The stipulation contents, probation terms, monitoring, and license conditions were reviewed and acknowledged by facility representatives and licensing officials.

Complaint involved allegations that a resident left the facility without staff knowledge. The investigation found the allegation substantiated based on evidence including interviews, documentation, video surveillance, and law enforcement reports.

The investigation substantiated that the facility failed to ensure a resident with dementia did not leave unaccompanied, posing an immediate health and safety risk. Other allegations regarding rate increases, family notification, and emergency services call were found unsubstantiated.

The complaint alleged that the facility was not abiding by the admission agreement. The investigation concluded the allegation was unfounded, meaning it was false or without reasonable basis.

The investigation found the allegation to be unfounded after reviewing resident documentation, interviews with facility staff, and billing statements. The resident's level of care change and associated costs were properly documented and communicated.

The complaint alleged the facility was not in good repair due to water leaks in a resident's apartment. The investigation included interviews with staff and residents, review of work orders dating back to 2013, and contractor invoices. The facility took corrective actions including gutter cleaning and sealing overflow to prevent leaks. The allegation was found unsubstantiated.

The investigation found that the facility promptly addressed the water leak issue through internal remediation and external vendor services. The allegation was determined to be unsubstantiated due to insufficient evidence to prove the violation occurred.

The medication technician misinterpreted a medication order and prepared two vials instead of one, but the resident refused the medication, so it was not administered. No deficiencies were cited from this case management inspection.

The facility made appropriate follow-ups regarding the resident discussed in the SOC 341 and confirmed the resident still resides at the facility. No deficiencies were cited during this case management inspection.

No deficiencies were cited during this visit. The facility staff is working with residents and responsible parties to address health condition changes and update care plans accordingly.

The facility reported no deficiencies during the visit. The resident returned safely the following day with no adverse reactions to missed medication doses. The facility plans to obtain contact phone numbers for residents when they leave with escorts or visitors.

The report discussed substantiated complaints filed against the facility, including those on August 6, 2021 and April 8, 2020, as well as a summary of complaints since 2016.

No deficiencies were cited during this visit. The report summarizes past citations including 8 Type A and 15 Type B citations since 2016, with 1 Type A and 3 Type B violations in 2021. The facility agreed to submit a compliance plan addressing resident care and staffing issues.

The complaint alleged unlawful eviction of a resident. The investigation included interviews with staff and review of facility policies and notices. The allegation was found to be unfounded.

The investigation found the allegation of unlawful eviction to be unfounded. The facility issued a 30-day termination notice to a resident for failure to comply with community policies, specifically unsafe operation of a motorized scooter, but the allegation was determined to be false or without reasonable basis after review of records and interviews.

The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited during the inspection.

The facility failed to submit the required 30-day written notice to terminate a resident (R1) to the licensing agency, which poses a potential health, safety, and personal rights risk to residents in care.

The complaint investigation substantiated that the facility staff failed to respond timely to resident R1's emergency calls on December 22, 2019, resulting in the resident's death. The allegation was substantiated and cited under CCR Title 22, § 87468.2(a)(8).

The investigation substantiated that on December 22, 2019, staff failed to respond to resident R1's emergency call device for approximately 40 minutes, contributing to the resident's death. Staffing shortages and staff duties contributed to delayed response times. A civil penalty of $14,500 was issued related to this violation.

The inspection found that the facility was in compliance with the posting requirements and disclosure to residents. The administrator showed the posted notice containing the required elements, and all 220 residents or their representatives were informed via written notice. No deficiencies were cited during this visit.

The Licensing Program Analyst completed required COVID-19 protocols, conducted interviews with residents, and delivered the exclusion letter to the administrator. An exit interview was conducted and a copy of the report was provided.

The complaint was substantiated. Staff member Carmencita Phelps admitted to abuse involving cold showers and verbal threats to residents R1, R2, and R3.

The investigation substantiated the complaint, finding that staff member Carmencita Phelps admitted to giving residents cold showers and verbally threatening them, posing an immediate health, safety, and personal rights risk. The facility terminated the staff member and conducted in-service training on elder abuse.

The complaint investigation was substantiated for allegations that staff did not shower the resident as scheduled, did not allow the resident to smoke, and did not supervise the resident during smoking. The allegations that staff did not ensure the resident was taken to doctor appointments and that the resident was charged for services not provided were unsubstantiated.

The investigation substantiated three allegations: staff did not assist the resident with scheduled showers, staff did not allow the resident to smoke as requested, and staff did not supervise the resident during smoking, which led to a fall. Two other allegations related to missed doctor appointments and being charged for services not provided were found unsubstantiated.

The complaint involved a resident (R1) who felt uncomfortable with a male staff member (S1) escorting her. The resident did not report abuse. The facility removed the staff from providing care to the resident and conducted an internal investigation. The Ombudsman also investigated and did not substantiate the allegation. The facility provided in-service training on appropriate interactions with residents.

The investigation included interviews with staff, the Ombudsman, and review of resident documentation. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, though the facility conducted in-service training on appropriate resident interaction.

No deficiencies were cited during the call. The facility's visitation plan was reviewed along with relevant CCLD guidelines, and a follow-up was planned.