347000389-8-21-2025-59-AS-MSEY-DKXSHD-20250827135323

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000389
Report Date: 08/21/2025
Date Signed: 08/21/2025 05:09:06 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/19/2025 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20250319155453

FACILITY NAME:	ATRIA EL CAMINO GARDENS		FACILITY NUMBER:	347000389
ADMINISTRATOR:	STANSEL, DANA		FACILITY TYPE:	740
ADDRESS:	2426 GARFIELD AVE		TELEPHONE:	(916) 488-5722
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	325	CENSUS: 229	DATE:	08/21/2025
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Dana Stansel, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff inappropriately handled resident resulting in resident sustaining fracture.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on March 19,2025. LPA met with Dana Stansel, Administrator, and stated the reason for the inspection.

During the investigation, the Department interviewed multiple facility staff, including managers, and (3) residents, including resident (R1) who is the subject of the investigation. Additionally, the Department reviewed facility documentation and hospital medical records related to (R1). The results of the investigation are as follows:

Resident (R1) moved to the community in November 2023 with diagnoses of Rheumatoid Arthritis and Osteoporosis, A-fib, chronic back pain and Mild Cognitive Impairment. The results of the investigation are as follows:

*cont on 9099C-1..

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 59-AS-20250319155453

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ATRIA EL CAMINO GARDENS	FACILITY NUMBER: 347000389
	VISIT DATE: 08/21/2025

NARRATIVE

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9099C-1.. Allegation: Staff inappropriately handled resident resulting in resident sustaining fracture. The allegation states after resident (R1) vomited in the dining room, staff (S1) came to assist and grabbed (R1's) arm and yanked it and (R1) has had pain in their arm since this incident. (R1) requested to be sent to the hospital on 3/12/2025 due to experiencing weakness, pain in their right hand and a cold.

Documentation reviewed shows (R1) was sent to the Emergency Room on 3/12/25 for the chief complaint of weakness and right hand pain. An x-ray revealed (R1) had a possible distal and radial ulnar fractures. Facility records, specifically the physician's report, showed that resident had a prior diagnosis of rheumatoid arthritis and osteoporosis.

(R1) indicated they threw up in the dining room, but the Department was not provided with a specific date for this incident. The Administrator stated this incident occurred late January or early February 2025. (R1) stated that staff (S1) "responded to assist resident and grabbed their arm, ignoring resident's request to let go due to it causing them pain. (S1) denied grabbing or pulling on resident's arm, or physically abusing (R1) at any time,insisting she only "lightly touched" (R1's) hand. (S1) stated she was about to wipe resident's hand when (R1) told her to stop and she let go. The Administrator indicated (S1) went to get some wipes to assist (R1) and her touch was "very mild" when wiping (R1's) hand. Another resident (R2), witnessed the incident, and her statements corroborated with (S1's) statements. Additionally (R2) stated they did not feel (R1) was physically abused or mistreated.

The Executive Director/Administrator confirmed that staff (S1) did not have any prior complaints from other residents or staff. The Administrator explained that resident (R1) also did not report the suspected physical abuse until a month had passed and it was reported following a separate incident between (S1) and (R1) where (R1) felt (S1) had offended them by a comment she made. It was unknown how or when (R1) sustained the injury.

Based on information obtained, the allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

*cont on 9099C-2..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20250319155453

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ATRIA EL CAMINO GARDENS	FACILITY NUMBER: 347000389
	VISIT DATE: 08/21/2025

NARRATIVE

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9099C -2... During the interview process of the investigation, the Department received the following additional information that is unrelated to the allegation in this report, as follows:

Resident (R1) reported that staff, (S3) and (S4) were verbally abusive to them and staff (S4) grabbed their right arm. No other details provided.

LPA interviewed staff (S3) and (S4) who stated that they would both assist (R1) with repositioning in their bed. Both staff stated that (R1) would sometimes refuse assistance and staff would not force (R1) since it's right to refuse. One staff stated they would let (R1) take their time and assist when they were ready for staff to help Both staff denied being verbally abusive to (R1) and said (R1) had moments where they "would be irritated" with staff and observed (R1) to be rude to many other staff. Both staff indicated they never grabbed (R1's) arm or saw any other staff do so.

Based on information obtained, there was insufficient evidence to prove by a preponderance that this occurred.

Resident, (R3), stated client (R4's) clothing and jewelry have been stolen. No details or dates of missing items were provided, but the incidents were allegedly reported to an unidentified facility staff but nothing has been done about it. (R3) indicated that (R4's) health has declined over the last 3 years and was not sure if this was related to the missing items.

The Administrator stated on 8/21/25 that (R4) reported a missing shell sweater to her and that she found the missing item in (R4's) closet, which was stuffed, and took a picture and showed (R4). The Administrator was not aware of any other items belonging to (R4) that were reported missing. Staff (S3) stated that (R4) resides in a different building than where she or (S4) is assigned.

The administrator confirmed the facility is following their theft and loss policy and logging items when they are reported missing.

Based on information obtained, there was insufficient evidence to prove by a preponderance that this occurred.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025

LIC9099 (FAS) - (06/04)

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