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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000389
Report Date: 08/21/2025
Date Signed: 08/21/2025 05:13:15 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
05/05/2025 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250505122845
FACILITY NAME:ATRIA EL CAMINO GARDENSFACILITY NUMBER:
347000389
ADMINISTRATOR:STANSEL, DANAFACILITY TYPE:
740
ADDRESS:2426 GARFIELD AVETELEPHONE:
(916) 488-5722
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:325CENSUS: 229DATE:
08/21/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Dana Stansel, Administrator TIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not seek medical attention for a resident in care.
Staff does not allow resident access to their bedroom.
Staff did not assist a resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete and deliver findings to a complaint received on May 5, 2025 and met with Dana Stansel, Administrator, stating the reason for the inspection.

During the investigation, LPA interviewed the Administrator, Memory Care Director, (3) staff, a hospice nurse and resident (R1). LPA also reviewed paperwork from resident (R1's) facility file, including the physician's report, care plan, several incident reports related to recent falls. The results of the investigation are as follows:

Resident (R1) moved to the Assisted Living side of the community on November 30, 2024. After several repeated falls in March/April 2025, and being placed on hospice on April 8, 2025 and, resident was subsequently moved to the facility's Memory Care Unit. Diagnosis listed on the physician's report (April 14, 2025) note resident had Cerebral Atheroslerosis, hallucinations, repeated falls, hypertension and chronic pain syndrome. Resident passed on May 30, 2025, under hospice care.
*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 6
Control Number 59-AS-20250505122845
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 did not seek medical attention for a resident in care. The allegation states on Friday 05/02/2025, resident (R1) was "throwing up" after eating lunch, did not eat any food for two days and was very weak, and the staff did not take (R1) to see a doctor.

Facility documents show that (R1) was placed under hospice care on April 8, 2025 and remained under their care until they passed on 5/30/2025.

(R1) stated to LPA on 5/8/25, "Yes, I was really sick- I called my daughter, who was very concerned". (R1) stated she got sick after she ate soup and then "only had liquids for the next couple of days and asked for water".

One staff stated on 5/8/2025 that she is "not aware" of (R1) getting sick recently, and there have been "no changes" with resident's eating or drinking. A second staff was asked about (R1) getting sick and vomiting and commented, "it was only a phlegm- it was not vomiting- it was only one time, after lunch and before dinner. Hospice is aware". This staff explained that (R1) "likes coffee every morning and ate lunch that day", adding (R1) also likes soup, will eat a small lunch and sometimes also a small dinner. This staff explained "every time (R1) asks for juice or a snack, we give it to (R1)" and snacks are offered two hours after each meal also, and commented "we serve soup often".

A Med-Tech staff stated she recalls (R1) getting sick one time, after lunch, in early May 2025 but is not sure what caused (R1) to get sick. This staff stated (R1) would have "still been offered food and (R1) played with their food" a lot.

A friend of (R1) stated she visited (R1) on 5/2/2025 and observed that (R1) did not feel well and stated (R1) suffered from constipation which can cause vomiting. This individual stated that (R1) was very confused on this day and did not get sick from soup but from fish they ate and was not eating after getting sick. This person also stated that one staff told her they don't have enough staff to help take (R1) to the bathroom, which contributed to the constipation problem.

*cont on 9099C2.

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)
Page: 2 of 6
Control Number 59-AS-20250505122845
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.. (R1’s) family member stated she doesn't recall (R1) being sick on May 2, 2025 as (R1) has been under hospice care for 2 months, before moving to Memory Care Unit (MCU) from Assisted Living Unit (ALU) at the facility. The family member asserted "the MCU staff is good about calling me and would have called me if (R1) had gotten sick". Additionally, the family member stated she was visiting from out of state from Thursday to Sunday, prior to Monday, 5/5/25, and did not observe (R1) to be sick at all.

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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.


Allegation: Staff does not allow resident access to their bedroom. The allegation states the resident (R1) is high risk for falls and requires a staff to supervise them at all times. The allegation also states that (R1) often makes requests to go to their room, staff does not allow (R1) to go to their room and is required to sit in the living room in their wheelchair for the entire day.

The memory care director stated (R1) can't be left in bed, due to hallucinations and when (R1) is trying to ambulate, (R1) is falling. The Director asserted "No, (R1) is not prohibited from going in her room- we put (R1) in a recliner so (R1) can watch television". The Administrator explained "(R1) is a super friendly, fun lady- she is watched more and doesn't fall" when in the common area.

One care staff explained "there is not enough staff to be with her to have a 1:1, so in the living room, we always have eyes on (R1) and stated staff has to be with (R1) all the time. A second staff confirmed that (R1) was kept in the common area due to being a fall risk and (R1) would try to get up and then slip.

The Administrator stated the goal of memory care is to have as many residents as possible engaged with other residents in the common area. Residents will thrive better and have more eyes on them when in the common area, but staff will take residents to their rooms if requested.


*cont on 9099C-3..
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)
Page: 3 of 6
Control Number 59-AS-20250505122845
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-3.. On 5/8/2025, (R1) stated to LPA, "Yes, they tell me I can't go in my room and I have to be in the common area". LPA observed (R1) to be "slouching" in her wheelchair. (R1) stated she will be starting Physical Therapy soon and commented, "the wheelchair is making me weak" and confirmed they are no longer using a walker. (R1) explained that staff tell them to "sit up" and doesn't like the "wedge" (pillow) staff use.

A hospice nurse stated staff always take (R1) to the common area during the day when they visit and confirmed (R1) uses a wheelchair regularly, and slumps over, so “uses a Palmer cushion", to keep them upright.

A friend of (R1) stated on 4/29/25, that (R1) was "very confused and crying and was awake all night". There were (3) caregivers there and they put (R1) in the common area for many hours.

(R1’s) family member stated (R1) "was never told she could not go in her room and feels like a visitor put the idea in (R1's) head", commenting "(R1) hallucinates a lot".

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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.

Allegation: Staff did not assist a resident in a timely manner. The allegation states that resident (R1) has a rash on their back, has a topical medication prescribed, and (R1’s) rash is getting worse due to sitting in their wheelchair all day. The allegation further states that on 05/02/2025, (R1) made a request to go to the bathroom and the staff made (R1) wait as they were chatting. There were no staff names provided.

The Memory Care Director stated to LPA on 5/8/25 that on Friday, 5/2/25, when (R1's) friend told her she didn't feel (R1) "was getting enough attention and soon enough" and asked staff to toilet (R1) during her visit. The Administrator, stated that (R1) moved to the Memory Care Unit because they were falling in Assisted Living Unit and explained (R1) was "slumping out of their wheelchair". LPA observed (R1) to be using a device to assist with staying upright in the wheelchair when (R1) was observed on 5/8/25.

*cont on 9099C4...

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)
Page: 4 of 6
Control Number 59-AS-20250505122845
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-4.. The Memory Care Director stated that if a resident is scratching, they will be treated with anti-scabies creme and (R1) was prescribed Atarax creme, which is anti-itch and commented that (R1) continues to complain about itching, so she will request that hospice nurse talk to the doctor about changing the creme.

One care staff confirmed on 5/8/2025, "Yes, (R1) has a rash on her back. (R1) has creme and Med-Techs are putting the creme on". This staff stated she is not sure of the number of cremes that were used, but "one had to be left on overnight", and the hospice CNA gave (R1) a shower the next day. This staff stated staff take (R1) to the use the bathroom when they ask staff, and there are (6) staff, including Med-Techs, that work in Memory Care Unit and (R1) wears a brief but will also use the toilet.A second staff stated on 5/8/25 that hospice gave (R1) a 7-day ointment that help prevent itching, and the rash is "much better now than 3 weeks ago".

(R1) was asked if staff take them to the restroom when they ask and replied, "Yes, they help me go to the bathroom" and confirmed they had a rash and it was "itchy". (R1) stated they had "a shot and three different kinds of creme" used so far on the rash and will be starting Physical Therapy soon commented, "the wheelchair is making me weak". (R1) explained that staff tell them to "sit up" and they don't like the "wedge" (pillow) staff use.



A Med-Tech staff stated she does not recall that (R1) was constipated or needed medications to help with constipation. This staff stated she regularly helped (R1) use the restroom and (R1) never complained of constipation but instead complained of indigestion and would ask for soda, 7 up, Ginger Ale and crackers. This staff stated staff would assist (R1) 2x/shift in using the bathroom, before/after meals and when requested, and (R1) was "generally cooperative". This staff stated no other resident or any staff had a scabies diagnosis during this time frame.

A hospice nurse stated (R1) "had the rash before hospice" and when (R1) went on hospice, the hospice doctor made a referral to a dermatologist; however, the dermatologist never came out to see (R1) due to a billing issue". The hospice nurse stated (R1) was not given a scabies test but was treated two times for "suspected scabies" and administered Permethrin. This nurse responded that he goes to Atria "frequently" and often has "five to seven residents" he sees at one time and staff are regularly assisting (R1) and commented "Atria is on top of checking residents" to go to the bathroom. *cont on 9099C-5..
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)
Page: 5 of 6
Control Number 59-AS-20250505122845
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-5.. A friend of (R1) stated on 5/21/25 that (R1) has been "itching" a lot and it "could be scabies", and that (R1) was treated for scabies two times. The friend stated (R1) complained over the phone to her that she "can't sleep" as the rash did not disappear after "two treatments", and Hydrocortisone was given as if the doctors were treating an allergy.

A Med-Tech staff confirmed (R1) had a rash before starting hospice, and she applied prescribed creme to (R1's) arms, back and chest where there were red spots. This staff indicated she never saw (R1) scratch but would always complain their skin was itching. This staff also described the treatment where staff applied the creme and the next day, the hospice CNA gave (R1) a shower to rinse of the treatment. This staff stated another treatment had to be repeated.

(R1’s) family member stated the facility "never mishandled" the rash, and the hospice doctor, was "already looking at the rash when it broke out" and every time he would visit (R1). The family member stated (R1) was placed under hospice care before the rash appeared and over the last two weeks, the rash has improved a lot and there is currently "no rash".

The family member stated (R1) was given multiple ointments for the rash and treated for "scabies three times", adding (R1) was placed on hospice due to hallucinations and falls, and due to the hallucinations was "scratching a lot", which may have caused the rash. The family member was not sure if a scabies test was ever done but commented she felt there was "no neglect or abuse" and the facility "has been very good with all".

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint 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.

Exit interview. Copy of report provided.
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)
Page: 6 of 6