Inspection Reports for
Atria Evergreen Valley

The complaint was received on 2025-09-05 with allegations that the facility administrator was not consistently present and staff lacked supervision causing medication delays. The complaint was investigated through interviews, observations, and document reviews. The allegation about supervision was found unfounded, and the medication error allegation was unsubstantiated due to lack of preponderance of evidence.

The investigation found the complaint regarding lack of supervision and medication delays to be unfounded, with no gap in supervision for 3 months. A separate allegation about medication administration errors during staff training was unsubstantiated due to insufficient evidence. No deficiencies were cited during the visit.

The facility was found to be in compliance with no deficiencies cited during the annual inspection. The facility was observed to be sanitary, organized, and equipped with necessary safety features. Resident and staff records were complete and up to date.

The complaint alleged that staff unlawfully evicted a resident. The investigation included interviews with previous Executive Director, Resident Service Director, family members, hospital staff, and review of resident notes and communications with public health. The allegation was determined to be unfounded.

The investigation found the allegation to be unfounded after reviewing resident records, interviewing staff and family members, and confirming communications with public health and hospital officials. No citations were issued during the visit.

The complaint alleged that staff changed the resident's service plan without the consent of the resident's authorized person. The investigation included interviews with staff, residents, and family members, review of incident reports and correspondence. The allegation was determined to be unsubstantiated.

The investigation found that the resident had changes in physical and mental condition, including aggressive and wandering behavior, which led the facility to request a 24x7 1:1 private caregiver for safety. The allegation that staff changed the service plan without consent was found to be unsubstantiated due to lack of preponderance of evidence.

The complaint involved two allegations: 1) Facility staff did not provide a resident a bath for at least two months, and 2) Facility hired a private caregiver for a resident without the resident's DPOA's consent. Interviews and document reviews indicated the resident refused bathing for 8 weeks and the facility refunded the responsible party $3,462 for private care charges. The allegations were unsubstantiated due to insufficient evidence.

The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations occurred, resulting in the allegations being unsubstantiated. No deficiencies were cited during the visit.

The complaint included allegations that facility staff verbally abused residents, pushed a resident to the toilet seat, wrapped a resident's undergarment too tightly causing blood circulation constriction, and physically abused a resident by splashing water on their face. Multiple staff interviews and resident inspections were conducted. Although some staff reported observing inappropriate behavior by a staff member (S3), the overall evidence was insufficient to substantiate the allegations. The staff member S3 was suspended and terminated by the facility following an internal investigation. The complaint was ultimately unsubstantiated.

The investigation found no preponderance of evidence to substantiate the allegations of verbal abuse, physical abuse, or improper care practices. The complaint was determined to be unsubstantiated and no deficiencies were cited during the visit.

The complaint was unsubstantiated. Allegations included failure to bathe a resident for two months and hiring a private caregiver without DPOA consent. Interviews and document reviews showed the resident refused bathing and the responsible party signed a contract for private care. The facility refunded $3,462 to the responsible party. No violations were found.

The investigation found that the resident refused to bathe for eight weeks and staff could not force bathing, and that the facility hired a private caregiver with an electronic contract signed by the responsible party. However, there was insufficient evidence to substantiate the allegations, and no deficiencies were cited during the visit.

The inspection found the facility to be in compliance with all applicable regulations, with no deficiencies cited. Facility conditions, safety measures, and medication records were all satisfactory.

The complaint alleged that the facility was overcharging resident R1 for 1 on 1 care services from 7/1/2023 to 7/18/2023. The facility provided documentation and interviews showing the charges were for third-party services agreed upon by the responsible party, and the charges were ultimately settled between the facility and responsible party. The allegation was found unsubstantiated.

The investigation found that the facility charged for 1 on 1 care services provided by a third party, which was initially disputed by the responsible party but later settled. The allegation was unsubstantiated due to lack of preponderance of evidence, and no deficiencies were cited.

The visit was triggered by a complaint of elder abuse. The case management remains open for further investigation. S1 was suspended and statements were obtained from involved staff. The incident was reported by S2 to the Executive Director on 7/21/2024.

The investigation found that staff member S1 was witnessed holding down and forcing resident R1 to sit down. Staff member S1 was suspended pending the outcome of the internal investigation. No deficiencies were cited during this visit.

The visit was complaint-related due to a medication error incident. The case management will remain open pending further investigation.

The facility Medication Technician gave the wrong medication to a resident during breakfast on 04/14/2024. The resident's physician and family were notified, no adverse effects were observed, and the resident was monitored every two hours. The medication error was determined to be caused by human error, and the Medication Technician received a final warning.

The complaint alleged that staff did not resolve noise disturbance from another resident. The investigation was unannounced and included interviews with the Executive Director/Administrator, residents, and staff. The complaint was determined to be unfounded based on evidence and interviews.

The investigation found that the facility made multiple efforts to address the noise complaint, including sending a memo about quiet hours, installing acoustic panels, and suggesting relocation options. Interviews and observations concluded that the allegations were unfounded, with no other residents complaining and no deficiencies cited.

The visit was complaint-related due to a medication error incident. The medication technician (S4) did not administer medication to resident (R1), resulting in a missed dose. The resident's responsible party and primary care physician were notified. The staff member was suspended and terminated. The case management remains open pending further investigation.

The investigation confirmed the medication error based on electronic Medication Administration Records and observation of the missed dose. The responsible staff member was suspended and later terminated. The resident was reported to be okay after the incident.

The visit was complaint-related to investigate suspected abuse reported to the Department. No deficiencies were found.

No deficiencies were cited at this time as per California Code of Regulations Title 22. The report was reviewed with the Administrator and a copy was provided.

The facility was toured and inspected including common areas, resident rooms, and safety equipment. No citations were issued. Some trash cans were observed without covers, and the Executive Director stated they would be covered within 3 days. Infection control measures and PPE supplies were sufficient.

The allegation was that a resident injured herself while in care. The investigation was unsubstantiated based on interviews and record reviews, indicating insufficient evidence to prove the allegation occurred.

The investigation found that facility staff were unaware of the resident's depression and suicidal ideations prior to the incident. Records and interviews did not substantiate the allegation, and no deficiencies were cited during the visit.

The facility was found to be in compliance with no deficiencies cited. COVID-19 protocols and universal precautions were observed to be properly implemented, and staff were wearing masks with adequate PPE supplies available.

The visit was triggered by a complaint regarding a resident's missing ring. The complaint was investigated through interviews and record reviews, with no deficiencies found.

No deficiencies were cited during the visit. The facility staff confirmed that the resident did not disclose having the ring upon admission and that they will continue to remind residents to document personal property and valuables.

The investigation found that the resident did not disclose having a ring upon moving in, and staff were not aware of the ring. No deficiencies were cited during the visit.