Inspection Reports for Atria Hillcrest

The inspection was conducted as an unannounced subsequent Case Management – Incident visit following a self-reported incident and subsequent incident death report regarding Resident #1 involving a fall and discovery of a firearm on 05/11/2025.

The investigation found that Resident #1 was highly independent with no history of suicidal ideation and no indication of possessing a firearm. Police reported no evidence of foul play or suspicious activity, and the cause of death was ruled as suicide. No deficiencies were cited related to this incident.

The visit was complaint-related due to a self-reported incident and death involving Resident #1. The complaint was investigated through interviews, file reviews, physical plant tours, and police report review. The complaint was substantiated as the cause of death was suicide with no foul play.

The visit was an unannounced Case Management - Incident inspection triggered by a self-reported incident and subsequent incident death report regarding Resident #1 on 05/12/2025 and 05/13/2025.

During the visit, Licensing Program Analysts conducted a physical plant tour to ensure no immediate health and safety concerns, interviewed the Executive Director, six staff members, and two residents, and reviewed pertinent documents related to the incident. Further investigation may be conducted if needed.

The visit was complaint-related based on a self-reported incident and incident death report concerning Resident #1. No substantiation status is provided in the report.

The visit was conducted as an unannounced Case Management - Incident inspection following receipt of a self-reported incident and subsequent incident death report regarding Resident #1 on 05/12/2025 and 05/13/2025.

During the visit, Licensing Program Analysts conducted a physical plant tour to ensure no immediate health and safety concerns, interviewed the Executive Director, reviewed Resident #1's file, and obtained pertinent documents related to the incident. Further investigation may be conducted if needed.

The visit was triggered by a complaint incident involving Resident #1, with a referral made to the Community Care Licensing Division's Investigation Branch. The report does not state substantiation status.

The Licensing Program Analyst conducted an unannounced required annual visit to evaluate the facility's compliance with Title 22 Regulations and ensure health and safety standards are met.

The facility was found to be in compliance with regulations, with no deficiencies cited. Observations included proper operation of elevators, functional fire safety equipment, well-maintained resident rooms, stocked restrooms, and compliant medication storage. Infection control and emergency disaster plans were up to date, and emergency drills were conducted as required.

An unannounced complaint investigation visit was conducted in response to allegations received on 2024-05-29 concerning resident confinement, financial safeguarding, attempted poisoning, and medication mismanagement at the facility.

The investigation found insufficient evidence to substantiate any of the allegations. Staff and residents denied mistreatment or confinement, no financial abuse was found, and medication refusal by the resident was documented with no evidence of staff mismanagement or poisoning attempts.

The complaint investigation was unsubstantiated. Allegations included resident confinement by staff, failure to safeguard resident's funds, attempted poisoning, and medication mismanagement. Interviews and record reviews revealed no violations or supporting evidence for these claims.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-05-15 regarding allegations that the licensee did not issue an accurate refund and that staff did not provide care services as agreed upon.

The investigation found that the facility issued an accurate refund to Resident 1 according to the admission agreement, and the allegation regarding the refund was unsubstantiated. Regarding care services, although Resident 1's representative reported staff dropped the resident during transfers and that two-person transfer assistance was not provided, there was insufficient evidence to prove the facility failed to provide care as stipulated, and the allegation was unsubstantiated.

The complaint involved two allegations: 1) the facility failed to issue an accurate refund related to a New Resident Service Fee of $2,895.00, and 2) staff did not provide two-person transfer assistance as agreed upon. The investigation included interviews with residents, visitors, facility staff, and Resident 1's representative, as well as document reviews. Both allegations were found to be unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not provide a resident's records to an authorized representative.

The allegation that staff failed to provide resident R1's records to the authorized records company for over two months was substantiated based on interviews and records review. The facility was found to have delayed providing records despite multiple requests.

The complaint was substantiated. The allegation was that staff did not provide resident's records to the authorized representative despite multiple requests from 3/22/2024 to 6/28/2024. Staff #2 confirmed the records request was forwarded to the Legal Department and records were eventually provided on 6/28/2024.

The visit was an unannounced complaint investigation triggered by allegations of neglect/lack of care towards Resident #1 (R1), including failure to provide adequate care resulting in sepsis, malnutrition, and dehydration during COVID-19 quarantine.

The investigation found insufficient evidence to substantiate the allegations of neglect or lack of care. Medical records, staff interviews, and resident representative statements indicated no concerns of neglect. The resident's health issues were attributed to comorbidities including COVID-19, and no citations were issued.

The complaint alleged neglect/lack of care to Resident #1 (R1) resulting in sepsis from a urinary tract infection, malnutrition, and dehydration during COVID-19 quarantine. The investigation was unsubstantiated due to insufficient evidence supporting the allegations.

The visit was conducted as a complaint investigation following allegations received on 2024-02-05 regarding understaffing, neglect of incontinent residents, and unqualified staff attending residents.

The investigation found insufficient evidence to substantiate the allegations of understaffing, unqualified staff, and neglect of incontinent residents. Staff schedules and interviews confirmed adequate staffing and proper training, and residents reported timely assistance.

The complaint included allegations that the facility was understaffed, incontinent residents were left in soiled diapers for extended periods due to staff neglect, and unqualified staff were attending residents. The investigation deemed all allegations unsubstantiated based on record reviews, staff and resident interviews, and observations.

Unannounced complaint investigation visit conducted to address allegations that facility staff were not meeting the incontinence needs of residents and that staff had inadequate training.

The investigation found insufficient evidence to support the allegations. Residents and staff interviews, record reviews, and facility tours indicated that incontinence care needs were being met and staff training was adequate. No violations or citations were issued.

The complaint was unsubstantiated. Allegations included failure to meet residents' incontinence needs and inadequate staff training. Interviews and record reviews showed care needs were met and training was documented and sufficient.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-11-15 regarding resident care concerns including soiled clothing, room odor, and hygiene maintenance.

The investigation found insufficient evidence to substantiate the allegations. Observations and interviews indicated residents were clean, properly groomed, and rooms were odor-free. Staff reported regular care and cleaning practices were in place.

The complaint alleged that staff left a resident in soiled clothing and diapers, did not keep the resident's room free from odor, and did not maintain residents' hygiene. After investigation, all allegations were deemed unsubstantiated due to lack of evidence.

Unannounced complaint investigation visit conducted in response to allegations received on 11/07/2022 regarding medication distribution, hydration, monitoring of resident condition, and dietary needs at Atria Hillcrest facility.

The investigation found insufficient evidence to support the allegations that staff failed to distribute medication as prescribed, ensure hydration, monitor changes in resident condition, or meet dietary needs. All allegations were deemed unsubstantiated based on interviews, record reviews, and observations.

The complaint included allegations that staff did not distribute resident's medication as prescribed, did not ensure hydration, did not monitor for change in condition, and did not meet dietary needs. The investigation included file reviews, staff and resident interviews, and observations. The resident was found to be independent in medication management and not on the medication program. Staff provided water and food options appropriately. No violations were substantiated.

The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2023-11-06 regarding plumbing issues in a resident's room.

The investigation found that the facility did experience plumbing issues in 2023, but services were performed to fix the problems and the resident was moved to a new unit. The allegation was deemed unsubstantiated based on the review of interviews and documents.

The complaint alleged that staff did not prevent plumbing issues in Resident #1's room, which occurred three times in six months during 2023. The allegation was investigated through interviews and document review and was found to be unsubstantiated.

The inspection was an unannounced required annual visit to evaluate the facility's compliance with Title 22 Regulations and ensure there are no health and safety hazards.

The facility was found to be in compliance with no deficiencies cited at the time of the visit. Resident rooms, common areas, kitchen, restrooms, and outside areas were all observed to be well maintained and safe. Interviews with residents revealed no concerns.

The inspection was conducted as an unannounced complaint investigation regarding an allegation that the facility was trying to persuade residents or their responsible parties to change physicians or home health agencies to those preferred by the administration.

The investigation found insufficient evidence to support the allegation. Staff and residents confirmed that choices regarding physicians and home health agencies were made by residents and their responsible parties without undue influence from the facility. The allegation was determined to be unsubstantiated and no deficiencies were observed.

The complaint alleged that the facility was persuading residents or their responsible parties to change physicians or home health agencies for financial gain. The investigation included interviews with staff, residents, and review of documents. It was confirmed that residents have freedom of choice and the facility provides a list of agencies without coercion. The complaint was unsubstantiated.

The inspection was an unannounced complaint investigation conducted in response to allegations received on 2023-10-06 regarding charging for services not provided, failure to provide special diets as prescribed, and staff lacking criminal record clearance.

The investigation included interviews, observations, and record reviews. All allegations were found to be unsubstantiated due to insufficient evidence. The facility was observed providing housekeeping and cleaning services, residents confirmed receipt of special diet options, and staff records confirmed criminal background clearances.

The complaint investigation addressed three allegations: 1) Facility charging for services not provided; 2) Facility not providing special diets as prescribed; 3) Facility staff lacking criminal record clearance. All allegations were deemed unsubstantiated based on observations, interviews, and record reviews.

The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff force residents to do activities of daily living.

Interviews with staff and residents denied the allegation that residents were forced to participate in activities of daily living. Residents confirmed they make their own decisions and participate at their leisure. The allegation was deemed unsubstantiated due to insufficient evidence.

The complaint alleged that staff force residents to do activities of daily living. After interviews and record reviews, the allegation was found unsubstantiated.

The visit was conducted to investigate a complaint alleging that staff were not present to administer medication to residents during certain hours.

The investigation found insufficient evidence to support the allegation. Interviews with residents and staff, as well as a review of staffing schedules, confirmed that a medtech was available during the night shift to administer pain medication as needed.

The complaint alleged that no medtech was available from 10am to 6am, causing residents to wait 30 minutes to an hour for medication. The allegation was deemed unsubstantiated based on interviews and schedule reviews.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2022-12-08 regarding staff not following resident's admissions agreement, not providing an itemized list of fees, and not providing rent increase notice within 60 days.

The investigation found insufficient evidence to support any of the allegations. Residents reported activities are offered but would like more frequent options; bills are itemized and communicated; and rent increase notices were sent timely except for a few new residents. All allegations were deemed unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included staff not following resident admissions agreements, not providing itemized fee lists, and failing to provide rent increase notices within 60 days. Interviews and record reviews did not support these claims.

The visit was conducted to conclude an investigation regarding an incident that occurred on 08/24/2022 involving a physical altercation between a resident and a staff member.

The investigation found conflicting statements about the incident, with no physical evidence of injury on the resident. The staff member denied abuse, and although fault was not determined, the staff member was terminated to avoid future issues. No deficiencies were cited.

The complaint involved an incident where Resident #1 reportedly kicked Staff #1, who later alleged being punched by the resident. Interviews and inspections found no evidence of abuse. The complaint was not substantiated and no further follow-up was required.

The Licensing Program Analyst Elsie Campos arrived unannounced to conduct a required annual visit to ensure compliance with Title 22 Regulations and to check for health and safety hazards.

The facility was generally clean, well maintained, and in compliance with infection control and safety regulations. However, some maintenance issues were noted including broken cabinets in the memory care unit and a broken sugar bin in the kitchen. One staff member was found not properly associated with the facility, resulting in a civil penalty.

An unannounced Case Management - Deficiencies visit was conducted due to a deficiency discovered during a complaint investigation related to a COVID-19 outbreak that was not reported to Community Care Licensing.

The facility failed to report a COVID-19 outbreak in August 2022 affecting approximately nine residents and one staff member to Community Care Licensing, which poses a potential health, safety, and personal rights risk to residents in care.

The visit was triggered by a complaint investigation. The deficiency was substantiated as the Administrator failed to report the COVID-19 outbreak to Community Care Licensing.

The visit was conducted as a complaint investigation regarding an allegation that a resident was fed food against their religious beliefs.

The investigation found that the resident in question had moved out over two years ago, and residents choose their meals daily with accommodations made if they are unhappy. Staff continuously check with residents about their food preferences, and no evidence was found to support the allegation. The complaint was deemed unsubstantiated.

The allegation was that Resident #1 was intentionally tricked into eating pork against their religion. The investigation included interviews, record reviews, and observations, concluding there was insufficient evidence to substantiate the claim.

The visit was conducted to investigate an incident reported by the facility regarding Resident #1, alleging that Staff #1 punched them in the right calf area of their leg.

The Licensing Program Analyst conducted an unannounced case management incident visit including interviews, a plant tour, and a resident file review. Further investigation is required prior to issuing findings.

The visit was complaint-related, investigating an incident of alleged physical abuse by staff against a resident. Substantiation status is not stated.

The visit was an unannounced case management incident investigation conducted to investigate an elopement incident involving Resident #1 that occurred on 2022-07-17.

The investigation found that Resident #1 eloped from the facility unassisted on 2022-07-17, despite the presence of a front desk clerk and memory care staff training on elopement protocols. The facility failed to supervise the resident, posing an immediate health and safety risk.

The visit was complaint-related, investigating an elopement incident of Resident #1 on 2022-07-17. The facility reported the incident the following day. Resident #1 was found outside the facility unassisted, contrary to the physician's report stating the resident cannot leave unassisted.

The visit was an unannounced complaint investigation triggered by allegations received on 2021-09-17 regarding multiple concerns about resident care and staff conduct at the facility.

The investigation found insufficient evidence to substantiate any of the allegations, including staff causing a resident to expose himself, staff hitting a resident, failure to accord privacy, multiple falls, delayed response to call buttons, and failure to assist with medical appointments. All allegations were deemed unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included staff causing a resident to expose himself, staff hitting a resident, failure to accord privacy, multiple falls, staff leaving a resident on the floor, delayed response to call buttons, and failure to assist with medical appointments. Investigations included interviews with staff, residents, and review of records. No citations were issued.

The Licensing Program Analyst arrived unannounced to conduct a required annual visit with a specific emphasis on infection control practices and procedures.

No deficiencies were observed during the inspection. The facility was found to be in compliance with Title 22 regulations, infection control practices, and visitation requirements. Adequate supplies of food, PPE, and properly maintained safety equipment were noted.

The visit was an unannounced complaint investigation triggered by an allegation that staff did not appropriately care for a resident.

The investigation found insufficient evidence to support the allegation that staff failed to appropriately care for Resident #1. Resident and responsible party interviews did not corroborate the claims, and residents reported feeling comfortable and well cared for. No deficiencies were cited.

The complaint alleged that staff did not appropriately care for Resident #1. Interviews with the resident, responsible party, other residents, and staff did not substantiate the claim. The allegation was deemed unsubstantiated.

An unannounced required 1-year inspection was conducted focusing on infection control and compliance with Title 22 regulations.

The inspection found no deficiencies. The facility was in compliance with health and safety regulations, infection control practices were observed, and safety equipment was operational. The facility had adequate PPE supplies and housekeeping was actively maintaining cleanliness.

An unannounced Case Management - Other visit was conducted to discuss the serious illness/injury reporting requirement as per regulation 87211(a)(1)(D).

The facility failed to submit unusual incident/injury reports within the required seven days on multiple occasions, posing a potential health and safety risk to residents.

report_32_565800366_inx31_2025-07-25.pdf

report_12_565800366_inx11_2024-10-15.pdf