<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608685
Report Date: 05/30/2024
Date Signed: 05/30/2024 02:29:36 PM


Document Has Been Signed on 05/30/2024 02:29 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: 134DATE:
05/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:April Princesa & Venca AviviTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced case management visit pertaining to a resident eloping from the facility. LPA met with Venca Avivi Resident Services Director and Executive Director April Princesa, who was informed the reason of the visit.

LPA received (3) incident reports, pertaining to resident #1 (R1) eloping from the facility. (R1) physically moved in the facility on 05/03/2024. On 05/05/2024, (R1) was found wandering in the front parking lot of the facility, and was returned to the community. The second elopement was dated on 05/18/2024, and the 3rd was on 05/24/2024. LPA contacted the ED on 05/24/2024, to obtain further information regarding the incident. During today's visit, LPA conducted interviews and reviewed (R1s) records. (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's) family recently hired private companion/caregiver to accompany (R1) until (R1) could be admitted to the memory care unit. LPA was informed that (R1) will be admitted either on 05/31/2024 or 06/01/2024. (R1) is not allowed to leave the facility unassisted.

LPA discussed with both the Resident Services Director & Executive Director, regarding the concerns of staffing during dining room hours and residents who are diagnosed with dementia and residing on the assisting living (AL) side of the facility, that cannot leave the facility unassisted. LPA has cited the facility for a previous incident that dealt with the same issue, dated 03/14/2024. During this visit, a citation will be issued and a civil penalty will be assessed. The ED has been informed by the LPA, that the plan of correction (POC) for today's citation will be discussed with there legal team, and ED will contact LPA on 05/31/2024 by 5pm with confirmation on the plan to correct citation. This is an immediate health and safety risk to residents in care.

Citation issued, civil penalty, 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: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/30/2024 02:29 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: 05/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2024
Section Cited
CCR
87705(j)

1
2
3
4
5
6
7
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
1
2
3
4
5
6
7
The Executive Director, will email LPA by 5pm on 05/31/2024, informing LPA that she has contacted there legal team regarding the plan of correction that is required for today's citation and civil penalty. The ED will have (2) weeks from 05/31/2024, to submit the POC to LPA regarding's today's citation.
8
9
10
11
12
13
14
R1 is diagnosed with dementia, and eloped from the facility on (3) different occasions. This is an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2