197608685-7-28-2026-31-AS-NMAN-DXARYK-20260825132628

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608685
Report Date: 07/28/2026
Date Signed: 07/28/2026 12:43:20 PM

Unsubstantiated

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
02/27/2026 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20260227151826

FACILITY NAME:	ATRIA SANTA CLARITA		FACILITY NUMBER:	197608685
ADMINISTRATOR:	EDEN TOLENTINO		FACILITY TYPE:	740
ADDRESS:	24431 LYONS AVE		TELEPHONE:	(661) 254-9933
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91321
CAPACITY:	160	CENSUS: 120	DATE:	07/28/2026
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Tracey Paulk		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Resident sustained multiple unstgeable pressure injuries due to staff neglect

INVESTIGATION FINDINGS:

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Licensing Program Analyst, (LPA) Tuesday Cabiness conducted a subsequent visit to deliver final report for the above allegation. LPA spoke with the Administrator, and explained the reason for the visit .

At 12:15pm, LPA inspected the facility; no health and safety hazard were noted. On 03/03/26, LPA Abeye Duguma conducted an initial visit to investigate the allegation, at which time, LPA conducted a brief facility well check and obtained records relevant to the investigation. To conclude the investigation Woodland Hils South RO was assisted by the CCLD Investigation Branch.

During investigation on 3/10/26, between 10:35am to 12:17pm the department conducted interviews with witnesses that have knowledge about R1’s medical records and care and supervision in the facility.
Between 1:30pm to 3:30pm, the Department representative spoke with four (4) facility staff and
(Cont'd LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20260227151826

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: 07/28/2026

NARRATIVE

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three (03) residents from Atria Santa Clarita. Between 3:30pm to 4:00pm, the two (02) staff from the RCFE “Sunrise Studio City”, two (02) other witnesses including R1’s case managers/health care provider. and their responsible party were interviewed. R1 was interviewed at their current residence Mountain View Assisted Living on 03/10/26 around 4:30pm. In addition, on 06/01/26 at 1:00pm the department reviewed R1’s medical records previously requested from the Henry Mayo Hospital.

It was alleged that resident #1 (R1) was observed sustaining unstageable pressure wounds due to staff neglect/lack of supervision. Information received revealed that R1 was residing at Atria Santa Clarita from 2021 until 11/30/25. On 11/30/25 R1 moved to Sunrise Studio City, admitted to the hospital on 01/24/26 and subsequently on 02/06/26, moved to Mountain View Assisted Living. Staff from Atria revealed that R1 resided at the facility for over 4 years and transferred out to Sunrise Senior Living on 11/30/25. During R1’s stay in the facility, R1 was assisted as needed. R1 was largely independent and ambulatory, requiring only standby shower assistance. During standby assistance, staff observed no skin breakdowns/pressure ulcers on R1's body; nor record of any staff witnessing skin ulcers during their residency at the facility. All residents interviewed at Atria revealed that they were satisfied with the care and supervision provided by staff. R1 confirmed that they sustained two pressure ulcers after R1 arrived at Sunrise Senior Living on 11/30/25 and that the ulcers worsened under Sunrise staff's care. R1 verified that while residing at the Atria, they did not require repositioning as R1 was able to do so on their own.

Interviews with staff working for Sunrise Senior Living facility revealed the following: During R1's placement in the Sunrise facility as of 11/30/25, R1 lower body was not checked, and staff were unaware if R1 had any pressure ulcers. R1 received standby shower assistance by staff twice per week. Staff could not recall any pressure ulcers on R1 at any time during R1’s residency at Sunrise Senior Living. The two of R1’s Case Managers had knowledge of R1 unstageable pressure ulcers. They verified that between 11/30/25 and 01/24/26, R1 resided at Sunrise Senior Living. R1 went to the hospital on 01/24/26 and, subsequently placed at Mountain View from February 2026 to present. On 01/24/2026, R1 was transported to Henry Mayo Hospital from Sunrise Studio City for a fall, at which time, R1's medical assessment showed that R1 sustained several pressure ulcers described as unstageable and infected.

A review of medical records from Henry Mayo Hospital verified that R1 was admitted on 1-24/26 and was found to have "sepsis due to bilateral gluteal pressure ulcers and cellulitis" and "...found to have MRSA bacteremia".....(Cont'd LIC9099C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20260227151826

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: 07/28/2026

NARRATIVE

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Overall investigation concluded that although R1 sustained unstageable pressure injuries, there is no sufficient evidence to verify that a resident sustained unstageable pressure injuries while residing at the Atria Santa Clarita. Therefore, based on facility inspection, interviews and record review, the allegation is UNSUBSTANTIATED at this time.

No immediate health and safety hazards were noted during this visit.
Exit Interview conducted, and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2026

LIC9099 (FAS) - (06/04)

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