Inspection Reports for Atria El Camino Gardens

The inspection was a Required-1 Year unannounced visit conducted to ensure compliance with Title 22 regulations for the care home.

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 inspection was conducted as an unannounced complaint investigation following a complaint received on 03/19/2025 alleging that staff inappropriately handled a resident resulting in a fracture.

The investigation found insufficient evidence to substantiate the allegation that staff physically abused the resident. Interviews with staff, residents, and review of medical records indicated conflicting accounts, and the allegation was determined to be unsubstantiated. Additional unrelated allegations of verbal abuse and theft were also investigated but found to lack sufficient evidence.

The complaint alleged that staff member (S1) grabbed and yanked resident (R1)'s arm causing a fracture. The allegation was unsubstantiated after investigation. Additional complaints of verbal abuse by staff (S3) and (S4) and theft of resident (R4)'s belongings were also investigated and found to have insufficient evidence.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2024-10-10 regarding staff not according resident privacy and not safeguarding residents' mail packages.

The investigation found the allegation regarding resident privacy to be unsubstantiated, as evidence did not support the claim. The allegation about mail packages not being safeguarded was found to be unfounded, with no issues observed or reported.

The complaint investigation was triggered by allegations that staff did not accord resident privacy and did not safeguard residents' mail packages. The privacy allegation was unsubstantiated, meaning there was insufficient evidence to prove the violation. The mail safeguarding allegation was unfounded, meaning it was false or without reasonable basis.

The inspection was conducted as a case management follow-up on a recent incident report submitted regarding a resident who was not found in their apartment and was later found walking outside the community.

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.

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 inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not mitigating the spread of infectious outbreaks in the facility.

The investigation included interviews with staff and residents and a review of records. It was found that staff followed infection control guidelines and there were no confirmed outbreaks or concerns. The allegation was determined to be unfounded.

The complaint alleged that staff were not following infection control guidelines to mitigate the spread of outbreaks around Thanksgiving 2024. Interviews with three staff and three residents indicated proper infection control practices and appropriate care were provided. The allegation was found to be unfounded.

The visit was a case management follow-up conducted to review the closure of a death report visit related to an incident on 9/20/2024.

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 inspection was an unannounced required annual inspection conducted to assess compliance with health and safety regulations at the facility.

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 conducted as a case management visit regarding a death report the Department received on 09/19/2024.

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

The inspection visit was an unannounced complaint investigation triggered by an allegation that staff were not meeting the needs of the residents.

After extensive interviews and file reviews, the Licensing Program Analyst found the allegation to be unfounded, concluding that the allegation was false, could not have happened, and/or was without a reasonable basis.

The complaint alleged that staff were not meeting the needs of the residents. Interviews with residents and the Executive Director, as well as file reviews, showed no evidence supporting the allegation. The Executive Director stated that a help signal training will be provided for residents. The allegation was determined to be unfounded.

The visit was an unannounced quarterly case management visit conducted in accordance with the Stipulation and Order effective from 06/01/2022 to 06/01/2024 to review compliance with the stipulation.

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.

Unannounced complaint investigation visit conducted in response to allegations including illegal eviction and failure of staff to provide resident's responsible party with resident's records.

The investigation found both allegations to be unfounded. The illegal eviction allegation was disproven based on documentation of unpaid rent and legal eviction notices. The allegation regarding failure to provide records was unfounded as requested documents were provided multiple times to the responsible party.

The complaint investigation was triggered by allegations of illegal eviction and failure to provide resident's records. The allegations were found to be unfounded after interviews and file reviews.

The visit was an unannounced quarterly case management visit conducted in accordance with a Stipulation and Order effective from 06/01/2022 to 06/01/2024.

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.

The inspection was an unannounced complaint investigation visit conducted in response to an allegation that the facility was not maintaining a comfortable temperature for a resident in care.

After extensive interviews, file reviews, and room inspections, the investigation found the allegation to be unfounded, meaning the complaint was false, could not have happened, or was without a reasonable basis. The facility was found to provide alternative heating and air conditioning accommodations as needed.

The complaint alleged that the facility was not maintaining a comfortable temperature for a resident. The investigation included interviews with residents and the Executive Director, review of facility practices including provision of portable heating and air conditioning units, and documentation of a pending replacement request for the older HVAC system in the A wing. The complaint was found to be unfounded.

The inspection visit was conducted as an unannounced complaint investigation regarding an allegation that the facility was not allowing a resident to leave the facility.

The investigation included extensive interviews with residents and facility staff. The allegation was found to be unfounded, as the Executive Director required residents to sign out as a best practice protocol to ensure safe returning, and the resident in question chose not to leave after being informed they could leave.

The complaint alleged that the facility was not allowing a resident to leave. Interviews revealed the Executive Director stopped the resident and asked them to sign out prior to leaving, which is standard protocol. The resident became upset and chose not to leave after being informed they could. The allegation was determined to be unfounded.

The inspection was conducted as an unannounced complaint investigation following allegations that facility staff were not keeping the facility at a comfortable temperature for residents and that the licensee did not ensure the facility AC unit was in working condition.

After extensive interviews, file reviews, and room inspections, the Department found the allegations to be unfounded, meaning the complaint was false or without reasonable basis. The facility staff conduct daily checks to ensure comfortable temperatures, provide portable heating and air conditioning units as needed, and have submitted a request to replace older HVAC units.

The complaint was investigated and found to be unfounded. Allegations included failure to maintain comfortable temperature and non-working AC units. Interviews with residents and the Executive Director, along with document review, supported that the facility accommodates residents' heating and cooling needs.

The inspection visit was an unannounced complaint investigation triggered by an allegation that staff did not follow proper eviction procedures.

The investigation found that the allegation was unfounded. Documentation showed that the eviction letter was served in compliance with Title 22 Eviction Procedures, including required notices and referral services. Interviews confirmed the resident and Power of Attorney were aware of the rent arrears and eviction process.

Allegation: Staff did not follow proper eviction procedures. The allegation was found to be unfounded, meaning it was false, could not have happened, or was without reasonable basis.

The visit was an unannounced case management visit conducted due to a voicemail received from the Executive Director regarding facility matters.

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.

Unannounced case management visit conducted regarding incident reports received by the Department on October 17, 2023.

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 visit was an unannounced quarterly case management visit conducted in accordance with a Stipulation and Order effective from 06/01/2022 to 05/31/2024.

The facility was observed to be clean, safe, sanitary, and in good repair. The Stipulation and Waiver and Order were posted conspicuously, and documentation including daily emergency call audits, monthly staff training, resident care task audits, and incident reports were reviewed. The facility was found to be in compliance with the Stipulation and Waiver and Order.

Licensing Program Analysts arrived unannounced to conduct a required 1-year annual inspection of the facility.

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 inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2023-01-31 regarding unsanitary conditions, pest presence, moldy food, and improper hand washing procedures at the facility.

The investigation included interviews, observations, and records review. The Licensing Program Analyst found no preponderance of evidence to substantiate the allegations. The facility was found to be clean, free from pests, and compliant with Title 22 regulations. Allegations were determined to be either unfounded or unsubstantiated.

The complaint investigation was triggered by allegations that the facility was unsanitary, staff did not ensure the facility was free from pests, staff served residents moldy food, and staff did not follow proper hand washing procedures. The findings were that the allegations were either unfounded or unsubstantiated based on interviews, observations, and records review.

The inspection was an unannounced complaint investigation visit triggered by an allegation of illegal eviction and rough handling of a resident.

The investigation found the facility to be in compliance with eviction procedures and the allegation of illegal eviction was unfounded. The allegation that staff handled a resident in a rough manner was also found to be unfounded based on records review and interviews.

The complaint alleged illegal eviction and rough handling of a resident. The investigation included records review and interviews, including with the resident involved (R1). The resident admitted to being disrespectful to staff. The allegations were determined to be unfounded.

The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 2023-03-07 regarding interference with residents' packages/mail and financial abuse of a resident.

The investigation found the allegation of interference with residents' packages/mail to be unfounded based on records and interviews, including a signed waiver by the resident. The allegation of financial abuse was found to be unsubstantiated as there was insufficient evidence to prove the violation occurred.

Two allegations were investigated: 1) Facility interfering with residents' packages/mail, which was found to be unfounded. 2) Facility financially abused a resident, which was found to be unsubstantiated.

The inspection visit was conducted as an unannounced complaint investigation regarding an allegation that the facility tampered with a resident's records.

The investigation included interviews and record reviews related to the allegation. The evidence did not meet the preponderance of evidence standard, and the allegation was found to be unsubstantiated.

The complaint alleged that the facility tampered with resident R1's records to increase R1's rent. Interviews and record reviews showed multiple LIC 602 forms from October 2022 to January 2023, and authorization for medical information release was in place. The allegation was unsubstantiated based on the evidence.

The visit was a case management inspection conducted to review compliance with regulations related to changes in level of care and associated notifications.

The facility failed to provide a written notice within two days to resident R1 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 inspection visit was a Case Management Legal visit conducted unannounced in accordance with a Stipulation and Order effective from 6/1/2022 to 5/31/2024.

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 task audits and staff numbers were sufficient, and monthly staff training was conducted. No deficiencies were cited during this visit.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was overcharging a resident in care.

The investigation found the allegation to be unsubstantiated as there was not a preponderance of evidence to prove the alleged violation occurred. Charges for level of care and pre-admission fees were consistent with the signed admission agreement, and a disputed charge for medication services was credited back. Additional charges for private duty personnel were implemented by the facility due to a safety incident, but the resident did not agree to these services.

The complaint alleged that the facility was overcharging a resident. The investigation included interviews with staff and residents, review of admission agreements, invoices, and physician reports. The allegation was found to be unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-12-16 alleging that the facility did not issue a refund to a resident.

The investigation found that the allegation was unfounded. Documentation and interviews showed that the resident was charged appropriately according to the signed admission agreement, and a $530 charge for medication services was credited back when it was determined the resident was not receiving those services.

The complaint alleged the facility did not issue a refund to a resident for unnecessary charges. The allegation was found to be unfounded after review of admission agreements, invoices, staff interviews, and relevant regulations.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2023-01-12, including mismanagement of residents' medications, staff threatening residents, failure to release records, lack of dignity in treatment, failure to provide proper documentation to physicians, and false claims.

The investigation substantiated the allegation that the facility mismanaged residents' medications, specifically that resident R8 was not receiving medications as prescribed, posing an immediate health and safety risk. All other allegations, including staff threatening residents, failure to release records, lack of dignity, failure to provide documentation to physicians, and false claims, were found to be unsubstantiated based on interviews and documentation review.

The complaint investigation was substantiated for the allegation of medication mismanagement but unsubstantiated for allegations of staff threatening residents, failure to release records, lack of dignity, failure to provide proper documentation to physicians, and false claims.

An unannounced complaint investigation visit was conducted in response to an allegation that staff inappropriately interfered with a resident's sleep.

Interviews with residents and staff indicated that while some residents initially experienced sleep interruptions, after communicating their preferences, the interruptions ceased. The investigation found no preponderance of evidence to substantiate the allegation, resulting in an unsubstantiated finding.

The allegation that staff inappropriately interfered with resident's sleep was investigated and found to be unsubstantiated based on interviews and evidence collected.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-11-10 regarding staff not taking precautions for COVID-19 and the facility not conducting response testing due to a COVID-19 outbreak.

The investigation found the allegation that staff were not taking COVID-19 precautions to be unsubstantiated, as staff were observed wearing masks and visitors were redirected to screening points. The allegation that the facility was not conducting response testing during a COVID-19 outbreak was found to be unfounded, with documentation and interviews confirming testing was conducted and reported appropriately.

The complaint involved two main allegations: 1) staff not taking precautions for COVID-19, and 2) the facility not conducting response testing due to a COVID-19 outbreak. Both allegations were investigated through interviews with residents, staff, and the Executive Director, observations, and review of documentation. The first allegation was unsubstantiated and the second was unfounded.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-01-30 regarding interference with residents receiving mail and unsafe food service.

The investigation found the allegations to be unfounded, meaning the claims were false, could not have happened, or lacked a reasonable basis. The Executive Director confirmed residents have mailboxes and packages are delivered to the front desk without being opened by staff.

The complaint involved allegations that the facility was interfering with residents receiving mail and that food was not served in a safe or healthful manner. The reporting party did not provide further information and the allegations were found to be unfounded.

The inspection was a Required-1 Year unannounced visit to evaluate infection control compliance at the facility.

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 inspection visit was a Case Management Legal visit conducted unannounced in accordance with a Stipulation and Order effective from 6/1/2022 to 5/31/2024.

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 inspection visit was conducted unannounced to deliver complaint findings and issue a citation for a deficiency discovered during a recent complaint investigation related to a secured environment addendum not signed by the resident.

The facility was cited for failing to ensure that a resident signed the 'Secured Environment Addendum' dated 2/25/22, as it was signed by the resident's Power of Attorney instead, posing a potential personal rights violation. This deficiency was previously cited in 2018 for the same issue.

The visit was related to complaint #25-AS-20220426122233. The complaint was substantiated as the facility failed to obtain the resident's signature on the secured environment document, which was signed by the resident's Power of Attorney instead.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-04-26 regarding alleged violations of resident visitation rights, Covid-19 precautionary protocols, and resident placement appropriateness.

The investigation substantiated that resident visitation rights were violated when visitors were denied indoor visits and required to wear masks outdoors, based on family authorization rather than resident consent. The allegation that the facility was not following Covid-19 protocols was unsubstantiated as the facility consistently offered outdoor visits with mask requirements. The allegation that a resident was inappropriately placed was found to be unfounded based on medical documentation and care plans.

The complaint alleged violations of resident visitation rights, failure to follow Covid-19 precautionary protocols, and inappropriate resident placement. The visitation rights allegation was substantiated, Covid-19 protocol allegation was unsubstantiated, and placement allegation was unfounded.

The inspection was an unannounced case management visit conducted following the receipt of several incident reports involving multiple residents.

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

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 was an unannounced complaint investigation visit triggered by a complaint received on 2022-03-14 alleging that the facility was not allowing a resident to manage his own medications.

The investigation found that the resident was not allowed to manage his own medications because he was unable to identify the majority of his medications, their purposes, and side effects. The resident's physician's assistant rescinded prior authorization for self-management. The allegation was found to be unfounded.

The complaint alleged that the facility was not allowing the resident to manage his own medications despite the resident's request and physician indication that he could. The investigation included interviews with the administrator, regional nurses, the resident, and the resident's representative, and review of relevant documentation. The allegation was determined to be unfounded.

The visit was a Case Management - Legal/Non-compliance meeting held to review the stipulation adopted on 06/01/2022 and discuss next steps regarding the facility's probationary status.

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.

Unannounced complaint investigation visit conducted due to a complaint received on 2021-10-20 regarding a resident leaving the facility without staff knowledge.

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.

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.

Unannounced complaint investigation visit conducted in response to a complaint received on 2022-01-18 alleging inadequate supervision and inadequate food service to residents.

The investigation included interviews with facility staff and residents, and review of documentation. Both allegations—lack of adequate supervision and inadequate food service—were found to be unsubstantiated due to insufficient evidence to prove the alleged violations occurred.

Complaint involved two main allegations: 1) Facility does not have adequate supervision, including concerns about insufficient staffing affecting paperwork and resident care such as showers; 2) Staff did not provide adequate food service, including complaints about food quality, staffing shortages in the kitchen, and lack of vegetable servings. The investigation found these allegations unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-01-07 alleging that staff were not assisting residents with showering as often as needed and not assisting residents with ambulating to the restroom in a timely manner.

The investigation included interviews with staff and residents and review of documentation such as shower schedules and pendant response times. The allegations were found to be unsubstantiated as there was insufficient evidence to prove the alleged violations occurred. The facility demonstrated compliance with their policy goal for pendant response times, and residents reported receiving assistance as needed.

The complaint alleged that staff were not assisting residents with showering as often as needed and not assisting residents with ambulating to the restroom in a timely manner, resulting in poor hygiene and accidents. Interviews with Med-Techs and residents, as well as review of pendant response times and shower schedules, showed that while some delays occurred, the facility met its policy goals and residents generally received timely assistance. The allegations were determined to be unsubstantiated.

Unannounced complaint investigation conducted due to an allegation that the facility was not abiding by the admission agreement.

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 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.

Unannounced complaint investigation conducted in response to an allegation that the facility was not in good repair, specifically regarding water leaks in a resident's apartment.

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 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 inspection was an unannounced case management follow-up visit triggered by an incident report received on 03/09/2022 regarding a medication incident on 03/04/2022.

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 inspection was conducted as a case management follow-up visit after receiving a SOC 341 on 02/22/2022 to verify resident status and facility compliance.

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.

The visit was an unannounced case management visit to discuss a recent eviction notification received by Community Care Licensing for resident R1 and a recent fall by resident R2.

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 visit was a case management visit regarding an incident report received by the Community Care Licensing Division on 10/22/2021 involving a resident who left the facility unassisted and did not return the same day as expected.

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 visit was an unannounced office Non-Compliance Conference conducted to discuss the history of citations issued since 2016, substantiated complaints, and a civil penalty issued in August 2021.

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 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.

The inspection was an unannounced complaint investigation visit triggered by an allegation of unlawful eviction received on 09/09/2021.

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 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 inspection was a Required-1 Year unannounced visit to conduct an annual inspection utilizing the infection control domain.

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 visit was a case management visit conducted to review compliance related to deficiencies, specifically regarding the submission of a 30-day written notice to terminate a resident's stay.

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 visit was conducted as a Case Management - Other unannounced visit to deliver additional civil penalties regarding substantiated findings from a complaint investigation concluded on April 8, 2020, related to failure to respond timely to a resident's call button.

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 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 visit was an unannounced case management inspection to ensure the facility's compliance with Health and Safety Code 1569.38 regarding the posting of licensing reports and disclosure to new residents following the department serving an Accusation on 08/03/2021.

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.

Licensing Program Analyst Melana Llopis arrived unannounced to deliver a letter of immediate exclusion for staff (S1) and to conduct a case management 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 inspection was an unannounced complaint investigation visit triggered by a complaint received on 08/05/2021 alleging residents were not treated with dignity and respect, including being showered with cold water and verbally abused by an employee.

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

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-03-22 regarding allegations of inadequate resident care including failure to shower a resident, denial of smoking rights, and lack of supervision during smoking.

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 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 inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-03-08 regarding staff making a resident feel uncomfortable.

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.

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 visit was a Case Management call conducted via telephone due to Covid-19 and precautionary measures, to address concerns received regarding the facility's visitation policies.

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.