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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005251
Report Date: 09/03/2025
Date Signed: 09/03/2025 04:33:59 PM

Substantiated


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
02/04/2025 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250204095142
FACILITY NAME:ATRIA CARMICHAEL OAKSFACILITY NUMBER:
347005251
ADMINISTRATOR:DAVIS, KAYLAFACILITY TYPE:
740
ADDRESS:8350 FAIR OAKS BLVDTELEPHONE:
(916) 944-2323
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:95CENSUS: DATE:
09/03/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kayla Davis, Executive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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-Staff is not allowing resident to return to facility for re-entry.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director, Kayla Davis, to deliver complaint investigation findings regarding the above stated allegation.

During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation.

According to resident (R1’s) Physician’s Report LIC602A, dated January 31, 2024, they were diagnosed with a primary diagnosis of Dementia. Unusual Incident/Injury Report LIC624, dated January 24, 2025, indicated that, on January 23, 2025, R1 was wandering the hallways and opening other residents’ doors. R1 appeared confused and not at their baseline. R1 was transported to the hospital. R1’s Resident Notes, dated January 23, 2025, indicated that facility staff were notified by a resident that R1 had opened another resident’s door, waking them. Resident Notes indicated that staff responded and found R1 confused and not at baseline, so R1 was transported to the hospital.
**********************************************Continued on LIC9099-C**********************************************
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
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 3
Control Number 59-AS-20250204095142
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 CARMICHAEL OAKS
FACILITY NUMBER: 347005251
VISIT DATE: 09/03/2025
NARRATIVE
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Interviews with the Executive Director, Nurse, and Resident Services Coordinator indicated that R1 would be a good fit for the memory care unit at the care home. Hospital Records indicated that they spoke with facility staff on January 24, 2025 indicating that R1 could return to facility after lunch. Hospital was notified by facility on January 24, 2025 that R1 currently resides in assisted living and would be moved to memory care pending discussion with R1’s responsible party. Hospital completed an LIC602A for R1 to go back to the facility in memory care and faxed the form to the facility. R1’s Resident Notes, dated January 24, 2025, indicated that the facility spoke with R1’s responsible party and informed them about memory care placement for R1, and responsible party indicated ok. R1’s Residency Agreement, dated June 26, 2023, indicated that “If we determine that the level of care, we are providing you is not appropriate for your needs, we will implement a change in level of care and consult with you regarding the change. We will also inform your Responsible Person(s) of the need for an implementation of any such change”.

Hospital Records indicated that, on January 25, 2025, the facility notified them that they will not be accepting R1 back. R1’s Resident Notes, dated January 25, 2025, indicated that they are not able to take R1 back due to safety issues and concerns. Staff interviews indicated that medical records stated R1 is a high risk of accidental self harm/self neglect if left unsupervised. However, medical records obtained indicated that there was no evidence of any self-harm, suicidal or homicidal ideation, plan or intent.

Medical Records indicated that, on January 26, 2025, hospital staff spoke to R1’s responsible party who indicated that they would reach out to the facility to find out why they will not take R1 back as rent was paid until the end of the month. Medical Records indicated that R1’s responsible party assisted the hospital in finding placement for R1.

Based on documentation reviewed and interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250204095142
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 CARMICHAEL OAKS
FACILITY NUMBER: 347005251
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2025
Section Cited
CCR
87468.2(a)(20)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions...
This requirement is not met as evidenced by:
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Facility agrees to submit a statement of understanding of residents' rights to LPA by the POC due date of 9/17/2025.
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Based on records reviewed and interviews conducted, the facility did not accept resident (R1) back from the hospital, which poses a potential health, safety, and personal rights 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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
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