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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608685
Report Date: 09/29/2026
Date Signed: 09/29/2026 01:50:03 PM

Document Has Been Signed on 09/29/2026 01:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CLARITAFACILITY NUMBER:
197608685
ADMINISTRATOR/
DIRECTOR:		TRACEY PAULKFACILITY TYPE:
740
ADDRESS:24431 Lyons AveTELEPHONE:
(661) 254-9933
CITY:Santa ClaritaSTATE: CAZIP CODE:
91321
CAPACITY: 160CENSUS: 122DATE:
09/29/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Tracey PaulkTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit and met with Administrator Tracey Paulk. LPA informed the Administrator of the reason for the visit.

The case management visit was conducted in response to an incident report received by Licensing regarding Resident #1 (R1), who requires assistance to leave the facility. According to the incident report, R1 was found outside the facility walking on the sidewalk. Facility staff located R1 and escorted the resident back into the facility. During the visit, LPA also discussed with the Administrator previous incidents involving residents who were also found outside the facility without the required assistance.

LPA conducted a physical plant inspection, interviewed facility staff, and obtained and reviewed facility documentation related to the incidents. LPA obtained and reviewed training records provided by the facility regarding resident supervision and preventing residents from leaving the facility.

Based on the information obtained during the visit, LPA determined that the facility needs to address the concerns related to residents who require assistance and are leaving the facility without authorization or supervision. LPA discussed the importance of ensuring appropriate measures are in place to prevent further incidents and maintain the safety and supervision of residents. This is a health and safety issue to residents in care.

At this time, further follow-up may be necessary. LPA will discuss the concerns and findings with the Regional Office (RO) to determine the appropriate next steps.

Citation issued, appeal rights, exit interview and copy of report provided.

Nichelle Gillyard
Tuesday Cabiness
DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/29/2026 01:50 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 09/29/2026 at 12:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA SANTA CLARITA
FACILITY NUMBER: 197608685

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2026
Section Cited
CCR
87705(e)(5)

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Care of Persons with Dementia: (e) Licensees that use delayed egress devices on exterior doors and perimeter fence gates shall meet the following initial and continuing requirements: (5)Facility staff shall ensure the continued safety of residents if they wander away away from the facility without.
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Administrator submitted in-service trainings conducted for staff pertaining incidents involving residents who left the facility unassisted without supervision. POC cleared during visit.
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violating Sections 87468...This requirement was not met, evidenced by LPA received an incident report of (R1) leaving the facility unassisted, and was found by staff. LPA received other reports on similar incidents of residents eloping from the memory care unit. This is a health and safety risk to residents in care.
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Type B
10/06/2026
Section Cited
CCR87464(d)

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Basic Services: (d)...if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457...This requirement was not met, evidenced by, during today's visit, LPA
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Administrator submitted in-service trainings conducted for staff pertaining to incidents involving residents who left the facility unassisted without supervision. POC cleared during the visit.
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received an incident report of (R1) found by staff outside of the facility and who is not able to leave the facility unassisted. This is a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Tuesday Cabiness
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2026


LIC809 (FAS) - (06/04)
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