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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608685
Report Date: 03/14/2024
Date Signed: 03/14/2024 02:20:43 PM


Document Has Been Signed on 03/14/2024 02:20 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:ATRIA SANTA CLARITAFACILITY NUMBER:
197608685
ADMINISTRATOR:APRIL PRINCESAFACILITY TYPE:
740
ADDRESS:24431 LYONS AVETELEPHONE:
(661) 254-9933
CITY:SANTA CLARITASTATE: CAZIP CODE:
91321
CAPACITY:160CENSUS: 133DATE:
03/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Wendy RoseTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced case management visit pertaining to a resident eloping from the facility. LPA met with Wendy Rose, the Community Business Director; who was informed the reason of the visit. The Executive Director April Princesa was not available or at the community. During today's visit, LPA conducted a physical plant inspection of the entire facility, including all exit doors and interviewed staff. The following was revealed:

On 03/09/2024, resident #1 (R1) eloped from the facility, and was returned back to the community by the local police department. It was revealed to LPA, that R1 is diagnosed with dementia and was currently residing on the AL (Assisted Living) side until an opening for the memory care unit was available. It was also reported to LPA that R1 has a private companion/caregiver that works in the evenings with R1. The companion did not report to the facility to work with R1, the evening of the incident. R1 is not allowed to leave the facility unassisted.

The day of the incident, R1 left the facility approximately around 415pm, and staff was not made aware R1 was missing until a phone call received by a bystander who contacted the facility and spoke to the front desk receptionist, who reported, they saw R1 walking down the street from the facility. The bystander contacted the police, who picked up R1 by the freeway and returned to the community. R1 was not aware that R1 eloped and was returned.

Staff contacted the Executive Director and family was notified. Therefore, based on interviews, LPA determined there was a lack of care and supervision for R1, which caused R1 to elope and wander. This is an immediate health and safety risk to residents in care. At the end of the visit, LPA spoke to the ED and regarding the visit and citation that was issued.
Citation issued, appeal rights, exit interview, and copy of report provided.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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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Document Has Been Signed on 03/14/2024 02:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ATRIA SANTA CLARITA
FACILITY NUMBER: 197608685

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2024
Section Cited
CCR
87705(j)

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Care of Persons with Dementia: (j)The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met, evidenced by; based on interviews and information obtained
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Executive Director will contact LPA by 5pm on 03/15/2024, to discuss a plan of action on how they will prevent R1 from eloping again and other residents who are diagnosed with dementia and living in assisted living.
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R1 is diagnosed with dementia, and eloped from the facility and returned by the police. This is an immediate 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.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
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