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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000752
Report Date: 08/30/2023
Date Signed: 08/30/2023 09:41:42 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/18/2020 and conducted by Evaluator Lydia Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20201218140845
FACILITY NAME:ATRIA GOLDEN CREEKFACILITY NUMBER:
306000752
ADMINISTRATOR:WENTWORTH, NICOLEFACILITY TYPE:
740
ADDRESS:33 CREEK RDTELEPHONE:
(949) 786-5665
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:155CENSUS: 103DATE:
08/30/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:James D. CraddockTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Resident sustained multiple pressure injuries due to neglect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lydia Martinez conducted and unannounced visit to the facility to deliver findings on the above allegation. LPA identified herself and discussed the purpose of the visit with Administrator (AD) James Craddock. The complaint was investigated by the Department.

During the investigation, interviews were conducted with facility Administrator, staff and witnesses. Additionally, copies of Resident 1 (R1) records, Incident Report (LIC624), Kaiser Permanente Medical Records, and Apex Hospice Records were obtained and reviewed.

R1 was a resident of Atria Golden Creek since 8/30/2020. R1 was in the hospital on 11/29/2020 for altered level of consciousness due to UTI/sepsis and was discharged back to Atria on 12/04/2020. R1 was receiving hospice services from Apex Hospice Care, Inc. and was being seen by a nurse and health aide two times per week. R1 was in the hospital again on 12/17/2020 and multiple pressure injuries were found during R1’s admission into the hospital. R1 passed away at the hospital on 12/22/2020.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
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 5
Control Number 22-AS-20201218140845
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ATRIA GOLDEN CREEK
FACILITY NUMBER: 306000752
VISIT DATE: 08/30/2023
NARRATIVE
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Hospital records showed R1 arrived at the emergency department on 12/17/2020 at about 08:53 PM. Chief complaint was weakness as R1 had not been eating the past few days and has been weak and lethargic. R1 was diagnosed with severe sepsis with acute organ dysfunction, septic shock, dementia, myasthenia gravis, anxiety disorder, failure to thrive syndrome, sever protein calorie malnutrition, left ventricular mural thrombus, ischemic cardiomyopathy, coagulopathy, hypernatremia. Multiple pressure ulcers on left toe, right ankle, right lower leg, and coccyx (unstageable), right heel stage 1, and deep tissue pressure injury of right and left heel.

Apex Hospice Care was approved for R1 from 12/04/2020 – 03/03/2021; Primary diagnosis –
Senile degeneration. Records showed R1’s health was declining, with poor appetite, difficulty in swallowing, lethargic, and poorly responsive. Interviews with Apex Hospice staff (Registered Nurse, Licensed Vocational Nurse, Physician Assistant) revealed they observed left heel with suspected deep tissue injury, blister to right ankle, redness to buttocks, and bruising to upper and lower extremities during their visits, from 12/10/2020-12/15/2020. No other pressure injuries noted on R1’s body. Hospice staff stated they did not have any concerns regarding the pressure injuries, and they were monitoring R1’s condition at that time. Instructions were given to Atria care staff to apply calmoseptine, floating the heel, and to reposition R1 frequently as tolerated. All observations were documented on the visit notes. Hospice staff stated they notified appropriate individuals of R1’s declining health condition. Home Health Aide who came two times per week to assist R1 with bathing stated she did not observe any pressure injuries or bruises on R1’s body.

Atria Golden Creek records documents staff noticed R1 with swollen discoloration on left arm near antecubital area on 12/08/2020 and with redness in R1’s perineal area on 12/09/2020. Hospice, family member who is also a Power of Attorney (POA), and physician were notified and staff was to continue to monitor the area and follow Dr.’s orders (medicated powder). No other documentation regarding skin discoloration or pressure injuries were observed anywhere else on R1’s body. No other observation/notes for R1 from 12/11/2020 – 12/16/2020. Atria Golden Creek’s Executive Director Nicole Wentworth and Resident Services Director April Princesa were interviewed. Wentworth and Princesa were shown photographs of R1’s pressure injuries that were taken at the hospital (12/18/2020). Wentworth and Princesa acknowledged the pressures injuries were “severe”.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20201218140845
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ATRIA GOLDEN CREEK
FACILITY NUMBER: 306000752
VISIT DATE: 08/30/2023
NARRATIVE
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Both stated they were not made aware by their care staff of R1’s skin condition. Both stated, “We [care staff] missed it. We should have seen it.” Both could not provide an explanation as to how the care staff were not able to notice and document the pressure injuries. Wentworth stated R1 was residing in their facility and was under their care and supervision and took full responsibility. Wentworth stated she will provide additional in-service staff training for the care staff.

All necessary interviews have been conducted. Atria and Apex Hospice staff failed to observe, document, and treat all of R1’s pressure injuries prior to R1 being transferred to the hospital on 12/17/2020. The investigation provided sufficient evidence and corroborating information to Substantiate the allegation of Neglect/Lack of Care and Supervision of resident R1.

An exit interview was conducted with Administrator Craddoc. A copy of the following reports LIC9099, LIC9099C, LIC9099D, LIC421M, LIC9099A, LIC811, and Appeals Right was sent to email on file.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/18/2020 and conducted by Evaluator Lydia Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20201218140845

FACILITY NAME:ATRIA GOLDEN CREEKFACILITY NUMBER:
306000752
ADMINISTRATOR:WENTWORTH, NICOLEFACILITY TYPE:
740
ADDRESS:33 CREEK RDTELEPHONE:
(949) 786-5665
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:155CENSUS: 103DATE:
08/30/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:James CraddockTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff did not ensure a resident consumed the appropriate amount of fluids while in care
Staff did not ensure a resident was properly fed while in care
INVESTIGATION FINDINGS:
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Facility Communication log (12/03/2020 – 12/18/2020) and Hospice records (12/05/2020-12/17/2020) and interviews conducted show and support R1’s health was declining; with poor appetite/not interested in eating, difficulty in swallowing, lethargic, and poorly responsive. Interviews with R1’s daughter revealed she and her brother visited R1 every other day. R1’s daughter stated facility communicated with her when there were changes with R1, for example R1 was having difficulty swallowing and eating. Interview with Michelle Burns, Physician Assistant she visited R1 on 12/15/2020 and confirmed R1’s health was declining rapidly and R1 was offered food and liquids but as people transition to passing away their appetite declines naturally.
Based on the evidence gathered through interviews and review of records, the allegations, Staff did not ensure resident consumed the appropriate amount of fluids while in care and Staff did not ensure resident was properly fed while in care are deemed Unfounded, meaning the allegations are false, could not have happened and/or are without a reasonable basis. An exit interview was conducted, and a copy of the report provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20201218140845
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ATRIA GOLDEN CREEK
FACILITY NUMBER: 306000752
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2023
Section Cited
CCR
87464(f)(6)
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Basic services shall at a minimum include: Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by:
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Administrator states will conduct in-service training on section cited. Will provide proof of training to CCL by POC due date of 9/8/2023.
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Based on interviews conducted and record reviews, R1 developed pressure injuries under facility’s care. Facility failed to observe, document and treat R1's pressure injuries in a timely manner. This poses an immediate risk to the health & safety of the resident in care.
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*Immediate civil penalty assessed*
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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.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5