Inspection Reports for Atria Evergreen Valley

The inspection was an unannounced required 1-year annual inspection conducted by the Licensing Program Analyst to evaluate compliance with licensing requirements.

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 visit was conducted as an unannounced Case Management visit to cite the facility for a deficiency found as part of a complaint investigation for a complaint received by the department on 04/13/2023.

The Licensing Program Analyst observed that resident R1's facility file did not contain a Safeguard for Property and Valuables form, which posed a potential personal rights risk to residents in care. A Type B deficiency was cited under California Code of Regulations Title 22.

The visit was triggered by a complaint received by the department on 04/13/2023. The deficiency cited relates to the complaint investigation.

The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-02-15 alleging that staff changed a resident's service plan without the consent of the resident's authorized person.

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 the resident. The facility communicated with the resident's family members regarding this need. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

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

The visit was an unannounced complaint investigation triggered by allegations that facility staff did not provide a resident a bath for at least two months and that the facility hired a private caregiver for a resident without the resident's DPOA's consent.

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 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 inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2023-12-28 regarding verbal and physical abuse of residents and improper care practices at the facility.

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 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 inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-04-16 alleging that staff did not respond to residents' requests for assistance in a timely manner and that complaint information was not posted as required.

The investigation found that the allegations were unsubstantiated and unfounded. Staff generally respond within 10 minutes to pendant calls, with occasional delays due to unavoidable circumstances. Complaint information was properly posted in the facility. No deficiencies were cited during the visit.

The complaint alleged that staff did not respond timely to residents' requests for assistance and that complaint information was not posted as required. Interviews with residents, staff, and facility maintenance director were conducted. The investigation concluded the allegations were unsubstantiated and unfounded.

The inspection was conducted as an unannounced complaint investigation following a complaint received on 2024-08-27 alleging the facility did not identify a resident's need prior to admission that resulted in eviction.

The investigation found that although the resident's level of care changed after admission and the community could no longer meet the resident's needs, there was insufficient evidence to substantiate the allegation. No deficiencies were cited during the visit.

The complaint alleged the facility did not identify the resident's need prior to admission that resulted in eviction. The allegation was unsubstantiated due to lack of preponderance of evidence.

An unannounced annual inspection was conducted to evaluate compliance with California Code of Regulations Title 22 at the facility.

The inspection found the facility to be in compliance with no deficiencies cited. The facility was observed to have proper safety measures, adequate food supplies, and updated medication records.

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

The investigation found that the facility charged for 1 on 1 care services provided by a third party, which continued beyond the resident's transfer to memory care. The charges were disputed but ultimately settled between the facility and the responsible party. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that the facility was overcharging a resident for services. The investigation included interviews with the responsible party, former and current Executive Directors, and review of documents. It was found that 1 on 1 care services were provided by a third party and billed under one account. The charges were adjusted and resolved with no violations substantiated.

The visit was an unannounced complaint investigation triggered by allegations that staff cut a resident's hair without consent, provided a massage that caused neck pain, and retaliated against residents.

After interviews and document review, the investigation found the allegations to be unfounded. The resident was diagnosed with mental disorders contributing to behavior and confusion. No citations were issued.

The complaint alleged that staff cut a resident's hair without consent, gave a rough massage causing neck pain, and retaliated against residents. Interviews with staff, residents, and former and current administrators were conducted. The resident was found to have confusion and hallucinations. The complaint was determined to be unfounded.

An unannounced case management visit was conducted regarding an incident report of elder abuse involving staff and a resident.

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

The visit was triggered by a complaint of elder abuse. The incident occurred on 7/20/2024 around 6:00 p.m. in the common area. The case management remains open for further investigation.

The inspection was an unannounced case management visit for an incident reported on 2024-04-15 involving a medication error that occurred on 2024-04-14.

The facility Medication Technician gave a resident the wrong medication during breakfast on April 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 visit was complaint-related due to a medication error incident. The case management will remain open pending further investigation.

The inspection was conducted as an unannounced complaint investigation following an allegation received on 2023-11-29 that the facility did not resolve a resident's concern regarding noise disturbance from another resident.

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 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.

An unannounced case management visit was conducted regarding an incident report where resident R1 consumed a cleaning solution and was hospitalized but returned the same day with no change of orders.

The facility implemented increased monitoring of resident R1 every two hours and removed hazardous materials from R1's apartment. However, the resident's appraisal and care plan were not updated following the incident, posing an immediate risk to the resident's health. A deficiency was cited for failure to update the pre-admission appraisal and care plan.

The visit was an unannounced case management visit regarding an incident on 2023-09-25 involving a medication error where a medication technician did not administer a prescribed medication dose to a resident.

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

The visit was complaint-related due to a medication error incident. The medication error was substantiated based on investigation findings.

The visit was conducted to investigate an incident of suspected abuse that was reported to the Department.

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

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-03-09 regarding unmet resident hygiene needs, poor communication with family, inadequate room size, COVID-19 protocol noncompliance, room disrepair, failure to follow admission agreement, and staff knowledge of hospital bed operation.

The investigation substantiated that the facility failed to meet a resident's hygiene needs, did not properly communicate with the resident's family regarding COVID-19 vaccination status, and the resident's room was not large enough to allow easy passage with a wheelchair. Other allegations including COVID-19 protocol adherence, room repair, admission agreement compliance, and staff knowledge of hospital bed operation were unsubstantiated.

The complaint investigation was substantiated for failure to meet resident hygiene needs, failure to communicate properly with family regarding COVID-19 vaccination, and inadequate room size for wheelchair passage. Other allegations were unsubstantiated.

The inspection visit was an unannounced required annual inspection to evaluate compliance with licensing regulations.

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.

An unannounced complaint investigation visit was conducted in response to an allegation that a resident injured herself while in care.

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 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.

An unannounced Annual Required 1 Year visit was conducted to evaluate the facility's compliance with licensing requirements.

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.

An unannounced complaint investigation visit was conducted in response to allegations that staff spoke inappropriately to a resident and did not properly manage residents' medications.

The allegation regarding staff speaking inappropriately to a resident was substantiated, resulting in a cited deficiency related to residents' personal rights. The allegation regarding medication management was found to be unfounded with no deficiencies cited.

The complaint investigation was substantiated for inappropriate staff behavior towards a resident. The medication management allegation was unfounded based on interviews and record reviews.

The visit was an unannounced Case Management - Incident tele-visit to follow up on an incident report received on 2021-03-15 regarding a resident's missing ring.

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 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.

report_23_435202714_inx22_2025-05-30.pdf