197608685-7-16-2026-31-AS-TCAS-DW7PYK-20260721114404

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608685
Report Date: 07/16/2026
Date Signed: 07/16/2026 12:15:56 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2025 and conducted by Evaluator Tuesday Cabiness

COMPLAINT CONTROL NUMBER: 31-AS-20250122155506

FACILITY NAME:	ATRIA SANTA CLARITA		FACILITY NUMBER:	197608685
ADMINISTRATOR:	APRIL PRINCESA		FACILITY TYPE:	740
ADDRESS:	24431 LYONS AVE		TELEPHONE:	(661) 254-9933
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91321
CAPACITY:	160	CENSUS: 118	DATE:	07/16/2026
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Tracey Paulk		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility staff neglect resulted in resident sustaining a fracture

INVESTIGATION FINDINGS:

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This report is an addendum to the Licensing Report previously delivered to the facility on October 30, 2025. The report has been amended to correct the investigative findings and the citation issued to the facility. Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Tracey Paulk and explained the purpose of the visit.

As a result of the second-level appeal process, the Department conducted a comprehensive review of the available information. Upon further review, it was determined that revisions were necessary to clarify the factual basis supporting the investigative findings. Therefore, today's visit was conducted to amend the investigative report and correct the citation previously issued on October 30, 2025.

On January 24, 2025, the Woodland Hills South Adult and Senior Care Regional Office received a complaint alleging that facility staff neglect resulted in Resident #1 (R1) sustaining a fracture.
(Cont'd LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

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 4

Control Number 31-AS-20250122155506

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA SANTA CLARITA	FACILITY NUMBER: 197608685
	VISIT DATE: 07/16/2026

NARRATIVE

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A review of facility records, including reassessments and internal incident reports, revealed that R1's last annual assessment was completed on August 13, 2024, and identified the need for an increased level of care. Following that assessment, R1 experienced six documented falls on September 15, September 20, September 23, October 1, November 13, and December 6, 2024. Incident reports consistently documented that R1's legs gave out while being transferred by a single staff member.

The investigation further revealed that facility administration, including the Executive Director, Residential Services Director, and other responsible personnel, were aware of R1's significant decline in condition and repeated falls. Despite this knowledge, the facility failed to timely reassess R1, revise the care plan, or implement appropriate interventions, including a documented requirement for two-person assistance during transfers. The facility's failure to reassess R1 and address the resident's increased care needs placed R1's health and safety at immediate risk and contributed to the circumstances that resulted in R1 sustaining a fractured femur.

Therefore, based on interviews, record reviews, the allegation that facility staff neglect resulted in resident #1 sustaining a fracture while in the care, will remain SUBSTANTIATED.

Under Title 22, Division 6, Chapter 8, the following citations are issued and recorded on LIC9099D. In addition, a $500.00 immediate civil penalty is being assessed today due to violation of the Title 22 Regulations posing immediate danger to the resident’s health and safety.

The ED was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Citations issued, appeal rights provided, exit interview conducted and copy of report provided to ED.

(LIC9099C-page 3)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250122155506

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA SANTA CLARITA	FACILITY NUMBER: 197608685
	VISIT DATE: 07/16/2026

NARRATIVE

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That same day, the complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Sonia Torre.

The initial investigation was conducted by LPA Tuesday Cabiness on February 24, 2025, from 12:45 p.m. to 2:30 p.m. During the visit, LPA obtained facility and resident records, including Special Incident Reports (SIRs), the admission agreement, move-in documentation, fire department records, physician's reports, and resident assessments. Between January 25, 2025, and April 26, 2025, IB Investigator Torre conducted interviews with residents, staff, and witnesses, and reviewed additional resident records, medical records, and incident reports involving R1. Allegation: Facility staff neglect resulted in Resident #1 sustaining a fracture.

It was alleged that between September 15, 2024, and December 6, 2024, Resident #1 (R1) experienced six reported falls. The final fall, which occurred on December 6, 2024, resulted in a fractured femur.
According to the IB investigation and a review of the 911 audio recording, staff reported that R1 was unable to support their own weight, did not want to be changed while in bed, and required a higher level of assistance than previously identified.

Interviews with the Executive Director (ED) and the Residential Services Director (RSD) revealed that, due to R1's frequent falls, administration intended to reassess R1 in September 2024 to determine the appropriate level of care. However, the reassessment and implementation of an updated care plan were delayed because R1's responsible party was unavailable to participate in the meeting. The RSD stated that although staff provided two-person assistance with transfers when deemed necessary, this practice was temporary and not formally incorporated into R1's care plan because it was inconsistent with facility policy.

Interviews with direct care staff consistently identified R1 as a high fall risk whose condition had progressively declined. Staff acknowledged that R1 increasingly required two-person assistance with transfers due to recurrent falls and declining mobility; however, this increased level of assistance was never formally documented or incorporated into R1's service plan.

(Cont'd LIC9099C - page 2)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 31-AS-20250122155506

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA SANTA CLARITA	FACILITY NUMBER: 197608685
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/16/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/17/2026 Section Cited CCR 87405(h)(5)	1 2 3 4 5 6 7	Administrator - Qualifications and Duties...(h) The administrator shall...(5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs,	1 2 3 4 5 6 7	The Administrator will read Title 22 regulations, 87405 - Administrator Qualifications and Duties and submit to LPA in writing the regulations were read and understood.
	8 9 10 11 12 13 14	including those services identified in the residents' Pre-Admission Appraisals, …and Reappraisal. This requirement is not met as evidenced by; The Executive Director failed to take responsibility to ensure provision of services to R1 and to provide appropriate services identifies in R1’s appraisal/reappraisal. This poses an immediate risk to residents health and safety.	8 9 10 11 12 13 14
Type B 07/17/2026 Section Cited CCR 87464(a)(g)	1 2 3 4 5 6 7	Reappraisals...(a)The pre-admission appraisal…shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, and to keep the appraisal accurate. The resident appraisal as frequently as necessary to	1 2 3 4 5 6 7	ED will discuss with corporate and legal regarding the plan of corrections for the citation issued. LPA informed ED, that by 07/30/2026, a definitive plan needs to be submitted in writing to LPA, the facility's intervention plan for residents involving reappraisals for high fall risks and two person
	8 9 10 11 12 13 14	ensure (g) The licensee shall ensure corresponding changes are made in the care and supervision provided to resident. This requirement is not met as evidenced by; staff failed to update changes are made in care and supervision as required. This poses an immediate health and safety risk to residents in care,	8 9 10 11 12 13 14	assist will be created and implemented. A copy of the plan needs to be submitted to LPA. If additional time is needed, the Administrator will email LPA for more time.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC9099 (FAS) - (06/04)

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