Inspection Reports for
Atherton Court Alzheimer’s Residence

During the visit, the Licensing Program Analyst observed a strong smell of urine in the resident's room but found the resident in clean clothing and linens. Interviews and document reviews were conducted, and no deficiencies were cited.

The inspection found two Type A deficiencies related to unlocked medication cart and improper storage of germicidal wipes near food, both posing immediate health and safety risks. Additionally, a Type B deficiency was cited for lack of accessible emergency drill documentation. Plans of correction were provided and deficiencies were cleared or pending documentation submission.

The complaint included allegations that residents were not showered or changed timely, residents' needs were unmet due to staffing shortages, and staff were not following COVID-19 protocols. The investigation found no substantiation for these claims.

Based on interviews, observations, and records review, all four allegations were closed as unsubstantiated due to lack of evidence. No deficiencies were cited during the investigation.

The inspection found no deficiencies. The resident had multiple falls in recent months without apparent injuries, and the facility had implemented increased staff check-ins at night. The Executive Director will obtain and provide a death certificate to the Licensing Program Analyst.

The complaint was unsubstantiated due to lack of preponderance of evidence despite the allegation that medications were not dispensed as prescribed.

The investigation included interviews and document reviews, revealing that a hospice nurse administered medication to the wrong resident. However, there was insufficient evidence to prove the alleged violation occurred, and the allegation was unsubstantiated. No deficiencies were cited during the visit.

The complaint alleged inadequate staff supervision leading to multiple falls and injuries of Resident R1. After investigation, the allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The investigation included interviews and review of resident and hospice records. The data collected did not confirm the allegation, and the complaint was determined to be unsubstantiated.

The complaint included allegations of staff yelling at residents, rough handling, mismanagement of medication, unmet diapering and hygiene needs, and short staffing. The investigation involved interviews with staff, residents, witnesses, and review of medication records and staff training. The complaint was determined to be unsubstantiated or unfounded with no deficiencies cited.

All six allegations were found to be unsubstantiated or unfounded after interviews, file reviews, and observations. No deficiencies were cited and the complaint was closed without findings of violations.

The facility was inspected thoroughly including physical plant, resident and staff records, and safety equipment. No deficiencies were cited during the visit.

The complaint was unsubstantiated. The investigation included interviews, review of staff schedules, client rosters, physician's reports, and hospice notes. Progress notes indicated ongoing discussions with the resident's responsible party about increased needs.

The investigation found that the resident's falls were not due to staff neglect but rather a decline in the resident's health. No deficiencies were cited during the visit.

The facility was found to be in compliance with no deficiencies cited. The environment was safe and well-maintained, with adequate lighting, temperature control, and safety equipment. Staff and resident records were current and medications reviewed without issue.

The visit was triggered by a complaint related to an incident on 2022-11-08. The complaint was investigated and closed on the same day. No substantiation of injury or harm was found.

The investigation found no injuries, bruising, or marks on the resident involved in the incident. No deficiencies were cited during the visit. The companion of the resident involved was barred from the facility following the incident.

The inspection found the facility to be in compliance with infection control requirements, including sufficient PPE supplies, proper signage, locked sharps and toxins, frequent disinfection of common areas, and operable safety equipment. No deficiencies were cited during the visit.

The complaint alleged that the facility prevented contact with a resident's family. The allegation was unsubstantiated after investigation.

The investigation included interviews with staff, witnesses, and the complainant, and review of relevant documents. It was found that family members were able to have FaceTime and in-person visits with residents, with visits scheduled and temperature screening conducted. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The inspection found the facility compliant with infection control standards, including proper signage, sufficient PPE and supplies, COVID-19 screening, and functioning safety detectors. No deficiencies were cited during the visit.

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

The investigation found the allegation to be unfounded after reviewing records and conducting interviews, confirming that the responsible party completed and submitted the required physician's report form which was accepted by the facility.

The complaint was substantiated based on observations, records review, and interviews. The allegation was that a resident wandered from the facility unassisted, which was confirmed during the investigation.

The investigation confirmed that a resident (R1) left the facility unassisted on 2020-10-13, which was substantiated as a violation of CCR title 22. The facility reported the incident to the licensing authority and was cited for failure to monitor residents adequately, posing an immediate threat to resident health and safety.