Inspection Reports for
Atria Collwood

The complaint involved a report of missing money for Resident #1, who was admitted on 2025-10-14 and is currently hospitalized. The facility followed theft and loss protocols and investigated the incident. Resident #1 was documented as having no cognitive impairment and able to make their own decisions.

No immediate health or safety risks were observed and no deficiencies were cited during this visit. Additional case management and subsequent visits will be provided as needed.

The visit included discussions with the Executive Director and an exit interview. The report and Licensee/Appeal Rights were provided to the facility representative. No specific deficiencies or findings are detailed in the report.

The complaint alleged an unlawful eviction of Resident1 related to medication management non-compliance. The complaint was investigated and found unsubstantiated as the facility followed proper procedures and R1 remained non-compliant with medication management.

The investigation found that Resident1 had a history of non-compliance with medication management policies, including unsecured medications and failure to follow facility protocols. The complaint of unlawful eviction was determined to be unsubstantiated due to a preponderance of evidence showing R1 disregarded medication safeguarding policies.

The complaint alleged that the licensee did not allow Resident #1 to keep their own medication. The investigation included interviews, record reviews, and facility tours. The resident had expressed suicidal ideation, prompting the licensee to take protective actions including one-on-one supervision and medication management. Medical professionals provided differing assessments, with the primary care physician ultimately authorizing the resident to self-manage medications. The licensee continued to manage medications pending further documentation. The allegation was found unsubstantiated.

The investigation found that the licensee responded appropriately to a credible safety concern regarding the resident's suicidal ideation and took control of the resident's medications based on medical assessments. The allegation was unsubstantiated and no deficiency was cited.

The complaint alleged that staff were charging Resident1 for assistance with showering that was never provided. The investigation found that Resident1 had refused assistance as of May 2023 and had requested removal of showering assistance from their care plan in July 2023, which was approved by the Primary Care Physician. No evidence supported the allegation.

The investigation included staff and resident interviews and record reviews, and determined the allegation to be unsubstantiated due to lack of evidence supporting the claim.

The complaint alleged that staff were not assisting a resident with bathing. The investigation found that the resident refused assistance and had approval from their Primary Care Physician to shower independently. Interviews with staff and other residents found no issues with bathing assistance. The complaint was unsubstantiated.

The investigation included staff and resident interviews and record reviews, which revealed the resident had refused assistance with showering and had authorization to shower independently. The allegation was determined to be unsubstantiated due to lack of evidence.

The visit included an exit interview with the Executive Director, Julia Lopez, and delivery of an amended report. The document outlines the types of deficiencies and the process for correction, appeals, and penalties but does not list specific deficiencies.

The complaint alleged that staff were not addressing mold at the facility, specifically mold in Resident1's room caused by a roof leak. The allegation was unsubstantiated after investigation.

The investigation included interviews, facility tour, and record review. The allegation was found to be unsubstantiated as the residue around the air conditioner was determined to be dirt, not mold, and no maintenance requests or resident reports supported mold or leak issues.

The complaint was unsubstantiated. Allegations included staff not providing a comfortable environment and failure to ensure the resident's room was odor-free. Evidence showed staff efforts to manage the resident's behavior and maintain cleanliness, but the resident was noncompliant and eventually evicted.

The investigation found that Resident #1 exhibited disruptive and aggressive behavior, which staff attempted to manage by encouraging compliance with house rules and ultimately evicting the resident. Regarding the odor allegation, staff regularly cleaned the resident's room more than once per week, but the resident often refused assistance. Both allegations were unsubstantiated due to insufficient evidence.

The visit involved securing report signatures, delivering an amended report, and conducting an exit interview with the Maintenance Director. No specific deficiencies or violations are detailed in the report.

The complaint alleged that Resident1 had $50 bonds stolen from their room on November 27, 2024. Law enforcement did not take a police report due to lack of evidence. The facility failed to produce a required theft log for reported thefts over $25. Interviews revealed no other concerns of theft. The allegation was unsubstantiated.

The investigation included interviews, record reviews, and staff and resident interviews. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence, despite some discrepancies in facility record keeping regarding theft logs.

The complaint alleged unlawful eviction of Resident #1. The investigation revealed the resident was given a 30-day notice due to rule violations, refused to vacate, and was eventually removed by the Sheriff's office. The allegation was unsubstantiated.

The investigation found that the resident violated multiple house rules and the facility followed proper eviction procedures; therefore, the allegation of unlawful eviction was unsubstantiated.

The complaint was unsubstantiated. Allegations included neglect/lack of supervision causing resident altercation, staff not treating residents with dignity, and failure to assist a resident with incontinence care. Investigations included interviews with staff, residents, and the Executive Director, as well as facility observations.

The investigation found no substantiation for the allegations. Interviews and observations indicated no evidence of staff or resident assaults, mistreatment, or lack of incontinence supplies. The resident involved had left the facility and no injuries were confirmed.

The complaint alleged that staff did not respond to Resident #1's call for assistance with retrieving medication from under the bed and that the front desk did not answer the phone. The allegation was found to be unsubstantiated after investigation.

The investigation found that the allegation was unsubstantiated. Interviews revealed that the front desk phone line was sometimes transferred to a cordless phone which occasionally malfunctioned, but residents were advised to use call pendants for emergencies. Residents did not report concerns about staff response to calls, and the resident involved did not miss medication doses.

The complaint alleged questionable death due to lack of care and supervision resulting in a fall on July 20, 2024, and subsequent death on August 14, 2024. The allegation was unsubstantiated.

The investigation found insufficient evidence to prove neglect or lack of care and supervision by the facility. The resident's fractures were not the cause of death, and the allegation was unsubstantiated.

The complaint alleged that staff did not provide resident records within two business days. The investigation included interviews and record reviews and concluded the allegation was unsubstantiated.

The investigation found that the facility provided monthly itemized invoices as required, but did not generate cumulative itemized bills dating back to admission as requested by the resident. The allegation was determined to be unsubstantiated as the facility was not required to maintain cumulative billing records.

A wellness check was conducted at the facility with no health or safety issues identified. No deficiencies were cited or observed during this visit.

No deficiencies were cited during the visit. Follow-up visits or phone calls may be necessary before determining if a violation occurred.

The complaint alleged that staff did not provide a comfortable environment due to a resident yelling and slamming a door and early morning gardening work disturbing residents. The investigation found no supporting evidence and the complaint was unsubstantiated.

The investigation included interviews with residents, staff, and the Executive Director, and review of records. No evidence was found to substantiate the allegations, and the complaint was determined to be unsubstantiated.

No deficiencies were cited at the time of this continuation visit. The inspection included a facility tour and an exit interview with the Executive Director.

The Licensing Program Analyst conducted a review of resident, facility, and staff records, confirming compliance. The annual inspection was not fully completed due to time constraints and will be finished at a later date.

The visit was triggered by an incident report concerning Resident 1. No deficiencies were found during the investigation.

No deficiencies were cited during the unannounced case management visit. The Licensing Program Analyst conducted staff interviews and reviewed resident records.

The complaint alleged that staff did not provide a comfortable environment for a resident because another resident entered the resident's room causing distress. The investigation included interviews with residents, staff, review of physician's report, and outside agency investigation. The allegation was found unsubstantiated as the resident who entered was confused and did not actually enter the room.

The investigation found that the allegation was unsubstantiated. The resident who allegedly entered the complainant's room did so due to confusion as a new resident unfamiliar with the facility layout, and did not actually enter the room but interacted at the door entrance. The evidence did not support the claim that the environment was uncomfortable due to staff actions.

The Licensing Program Manager delivered two amended reports and obtained signatures from the facility representative. An exit interview was conducted and copies of the report and Licensee Rights were provided.

The complaint alleged that facility staff did not provide adequate toileting supplies. The investigation found no preponderance of evidence to substantiate the allegation, concluding it was unsubstantiated.

The investigation included staff and resident interviews and a facility tour. The allegation that residents were not provided adequate toileting supplies was found to be unsubstantiated based on interviews indicating residents received two rolls of toilet paper per week, which was deemed adequate.

The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.

Based on staff and resident interviews, facility records review, and a facility tour, the allegations were found to be unsubstantiated. Residents expressed satisfaction with housekeeping and laundry services, and no issues were observed with bathrooms or toilets during the visit.

The complaint alleged that staff were not ensuring residents were transported to their appointments. The investigation included interviews with staff and residents and review of facility records. The finding was unsubstantiated.

Based on staff and resident interviews and facility records review, the allegation was found to be unsubstantiated as there was no preponderance of evidence to prove the violation occurred. The facility maintains a transportation schedule accommodating residents' needs, and residents reported no issues with transportation.

The complaint alleged that staff did not provide a comfortable temperature for residents. The allegation was unsubstantiated after investigation.

The investigation included staff and resident interviews and a facility tour. It was found that each resident room has its own air conditioning unit which residents can control. Although one resident had trouble adjusting their AC unit, maintenance fixed the issue. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

During the visit, the Licensing Program Analyst obtained the Resident Service Assistant's signature on the amended report and conducted an exit interview, providing a copy of the report and licensee appeal rights.

The complaint alleged that staff did not provide transportation to a resident on August 27, 2024. Interviews and record reviews showed the transportation calendar was fully booked that day, and the resident was transported the following day. The complaint was unsubstantiated.

The investigation included interviews with residents and staff and a review of facility records. It was found that although the allegation may have occurred, there was insufficient evidence to prove a violation, and the complaint was determined to be unsubstantiated. The resident was provided transportation the following day, and other residents reported no issues with transportation services.

The complaint involved Resident 1 eloping from the facility on August 24, 2024. The resident was found by a neighbor who called 911, and the resident was returned to the facility by a family member later that evening.

No deficiencies were cited during the visit. The Licensing Program Analyst conducted interviews and record reviews, and follow-up visits or calls may be necessary before determining if a violation occurred.

The complaint alleged that staff did not treat a resident with dignity by yelling at the resident. The allegation was unsubstantiated after investigation.

The investigation found no evidence to corroborate the allegation that staff yelled at a resident. Interviews with staff, residents, and the Executive Director did not reveal any concerns or confirm the incident, resulting in the allegation being unsubstantiated.

The complaint was unsubstantiated based on the investigation findings.

The investigation included facility inspection, observation, record reviews, and interviews. It was determined that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the violation occurred, and the complaint was unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included failure to provide fresh fruit and staff communication barriers. Evidence did not support these claims.

The investigation found that fresh fruit was offered and served during each meal, with accommodations made for resident preferences and chewing/swallowing needs. Staff and residents reported no communication issues related to language barriers. The allegations were determined to be unsubstantiated based on interviews, observations, and records review.

The Licensing Program Manager delivered an amended version of a report, obtained signatures, and provided copies of the report and Licensee Rights to the facility representative during an exit interview.

The complaint alleged that staff did not provide resident with water. After investigation, including interviews with Resident 1, Resident 2, staff, and outside sources, and observation of multiple water stations and bottled water availability, the allegation was determined to be unsubstantiated.

The investigation included facility inspection, interviews with residents, staff, and outside sources, and observation of water availability. The evidence did not support the allegation, and the complaint was found to be unsubstantiated.

The complaint alleged poor plumbing with no running water in resident bathrooms on January 23, 2024. Interviews with residents and staff confirmed repairs were made the same day and alternative facilities were provided. The allegation was found to be unsubstantiated.

Based on interviews with residents, staff, and an outside source, observations, and records review, the investigation found that plumbing repairs were completed promptly on January 23, 2024, alternative bathrooms were provided during repairs, and residents were informed. Therefore, the allegation was unsubstantiated.

The allegation that staff did not meet a resident's needs was unsubstantiated based on interviews, record reviews, and observations.

The investigation found that Resident #1 was able to ambulate independently and had declined escorting services due to additional charges. The facility agreed to remove the charge and service, and there was insufficient evidence to substantiate the allegation.

The complaint included allegations that staff were not properly cleaning resident restrooms, not addressing pest infestation, not assisting residents in a timely manner, and not emptying resident trash cans. The investigation found these allegations unsubstantiated based on interviews, observations, and evidence gathered.

The investigation found insufficient evidence to support any of the allegations. Interviews with staff and residents, as well as observations, did not substantiate claims of improper cleaning, pest infestation, untimely assistance, or failure to empty trash cans. The allegations were determined to be unsubstantiated.

The complaint involved allegations that staff did not provide a resident with clean linens and that staff yelled at a resident. The investigation included interviews with staff, the resident, outside sources, and direct observations. The allegations were found to be unsubstantiated based on a preponderance of evidence.

The investigation found that the resident's bedding was changed according to their preference and requests, and no evidence supported the allegation that staff yelled at the resident. Interviews, observations, and records review led to the conclusion that the allegations were unsubstantiated.

The visit was complaint-related due to a self-reported incident of second degree burns involving Resident 1. No deficiencies were found.

A wellness check was conducted with no health or safety issues identified and no deficiencies cited or observed during the visit.

The complaint included allegations of unlawful eviction, failure to provide timely laundry service, and staff mismanagement of resident medication. All allegations were found unsubstantiated based on interviews, record reviews, and observations.

The investigation found insufficient evidence to support the allegations. The eviction was lawful due to nonpayment, laundry services were provided timely according to staff and resident interviews, and medication management was not mishandled by staff as the resident self-managed medications.

The complaint alleged that staff handled residents in a rough manner and did not treat residents with dignity. The investigation included interviews, record reviews, and direct observations, all of which did not support the allegations. An outside agency investigation also found no evidence to validate the claims. The findings were unsubstantiated.

The investigation found no evidence to substantiate the allegations. Interviews with staff, residents, and outside sources, as well as direct observations during three unannounced visits, did not corroborate claims of rough handling or disrespectful treatment. The allegations were deemed unsubstantiated.

The complaint alleged staff verbally assaulted a resident by saying the resident was suicidal and implemented one-to-one supervision without consent, and falsely accused the resident of making threats to kill relatives. The investigation found the resident denied making threats and refused treatment, and the facility did not charge for additional supervision. The allegations were unsubstantiated based on the preponderance of evidence.

The investigation found insufficient evidence to support the allegations. Interviews, record reviews, and outside sources indicated that the allegations were unsubstantiated, and the facility's actions, including one-to-one supervision, were based on safety concerns and consistent with facility policy.

The facility was found to be in substantial compliance with regulations, with clean and sufficient linens, properly equipped resident rooms, sanitary bathrooms, operational safety equipment, proper food storage, compliant medication administration, complete staff and resident records, and sufficient staffing to meet residents' needs.

The complaint alleged that Resident 1 was unlawfully evicted. The investigation determined the allegation was false and without reasonable basis, as the eviction notice complied with Title 22 mandates.

The investigation found the allegation of unlawful eviction to be unfounded after reviewing facility records and conducting interviews. The facility was in compliance with Title 22 regulations at the time of the visit.

The complaint alleged management retaliation against a staff member regarding reporting requirements. After investigation, the allegation was found unsubstantiated due to lack of corroborating evidence.

The investigation found no corroborating evidence to support the allegation of retaliation. Interviews with staff and management revealed misunderstandings, and the complaint was determined to be unsubstantiated.

The complaint investigation addressed two allegations: 1) Resident food was not of quality, which was unsubstantiated. 2) Facility did not itemize resident's bill, which was unfounded.

The investigation found the allegation of poor food quality unsubstantiated due to lack of evidence and resident/staff interviews confirming good food quality. The allegation that the facility did not itemize a resident's bill was unfounded based on billing records and staff interviews showing proper billing procedures and timely provision of itemized statements.

The complaint alleged that staff did not deliver resident's mail in a timely manner. Interviews and records review showed mail was typically delivered by the next day. The allegation was unsubstantiated.

The investigation found that mail delivery to residents' rooms generally occurred no later than the day after mail was received by the facility. There was no contractual agreement for mail delivery to rooms, and the one-day delay did not support the alleged violation. The complaint was determined to be unsubstantiated due to lack of corroborating evidence.

The complaint alleged the facility was in disrepair due to HVAC issues causing temperature discomfort. Investigation included interviews with staff and resident, review of work orders, and direct observation of the HVAC unit. The resident preferred room temperatures between 80-83 degrees Fahrenheit, and the unit was functioning within that range despite a missing dash on the digital display.

Based on observations, record reviews, and interviews, there was no preponderance of evidence to prove the alleged violation occurred; the complaint was found to be unsubstantiated.

The complaint alleged that the licensee did not assist Resident 1 in obtaining medical and dental care. The allegation was found to be unsubstantiated due to lack of evidence.

The investigation found that prior to the resident's relocation to a higher level care facility, the resident was independent in self-care and regularly received medical and dental care. There was no evidence to corroborate the allegation, and the complaint was unsubstantiated.

The complaint investigation was unsubstantiated due to lack of corroborating evidence despite multiple allegations including failure to address scabies, failure to address resident's change in medical condition, and failure to provide transportation as per the Admission Agreement.

The investigation found that although there were allegations of staff failing to address scabies, medical condition changes, and transportation issues for Resident 1, the evidence was insufficient to substantiate these claims. Facility staff implemented universal precautions after scabies diagnosis, but documentation and coordination issues were noted.

No deficiencies were cited during this inspection. The Licensing Program Analyst conducted a tour, observed staff and residents, and reviewed the facility's COVID-19 Mitigation Plan implementation.

The Licensing Program Analyst toured the facility, performed welfare checks on the residents involved, interviewed relevant staff and residents, and reviewed care records. No deficiencies were cited during the visit.

The complaint involved unwelcome verbal comments and touching between Staff Member 1 and Resident 1. Staff Member 1 was suspended pending investigation.

The Licensing Program Analyst conducted a welfare check on the resident involved, interviewed the administrator, and reviewed relevant records. No deficiencies were cited during the visit.

No deficiencies were cited during the visit. The facility had suspended and subsequently terminated the employment of the staff member involved in the incident.