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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850335
Report Date: 07/26/2024
Date Signed: 07/26/2024 12:07:31 PM


Document Has Been Signed on 07/26/2024 12:07 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:GRANVIDA SENIOR LIVING AND MEMORY CAREFACILITY NUMBER:
425850335
ADMINISTRATOR:TERRILL, ERICFACILITY TYPE:
740
ADDRESS:5464 CARPINTERIA AVENUETELEPHONE:
(805) 566-0017
CITY:CARPINTERIASTATE: CAZIP CODE:
93013
CAPACITY:83CENSUS: 57DATE:
07/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Eric Terrill, AdministratorTIME COMPLETED:
12:00 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
On 07/26/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced case management-Incident visit. LPA met with Administrator Eric Terrill and announced the purpose of the visit. The Licensing Agency received Incident Reports from the Licensee dated 06/12/2024, 06/19/2024, and 07/14/2024 regarding three (3) elopements from the facility within an approximately one (1) month period by Resident #1 (R1) in which the following was stated to have occurred:

On 06/12/2024, R1 eloped from the facility through the front door of the Memory Care Unit. Facility Staff responded immediately and R1 was redirected back into the facility. R1 appeared agitated and PRN medications were administered upon return to the facility. On 06/19/2024, R1 again eloped from the facility and Staff were notified due to a wandering transmitter alert at the Memory Care Unit courtyard fence. Staff were unable to locate R1 at the time of elopement at 12:32am and subsequently called 911 as well as filed a missing persons report with Law Enforcement. R1 was found at 12:57am by Law Enforcement with a laceration on their forehead and transported to the hospital Emergency Room (ER). R1 was returned to the facility with a follow up treatment plan to have an assessment of the PRN medication for R1 by R1’s primary care physician (PCP) and facility Staff to increase additional supervision of R1. On 07/14/2024, R1 again eloped from the Memory Care Unit of the facility. Staff responded to the functional alarm system alert at the Memory Care Unit gate, but R1 was already on the front lawn of the facility by the time staff arrived. R1 was redirected back into the Memory Care Unit of the facility, and both the relative of R1 as well as the PCP for R1 were notified. This incident report indicates that the care plan for R1 has been updated to reflect the wandering and elopement behaviors.

A citation and civil penalty is issued for repeated elopements from R1 on 6/12/2024, 6/19/2024, and 7/14/2024. The 6/19/2024 elopement caused injury to R1 and law enforcement response to missing persons report, which posed an immediate health and safety risk to residents in care. Exit interview conducted. A copy of the report was issued to the facility.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024
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 07/26/2024 12:07 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: GRANVIDA SENIOR LIVING AND MEMORY CARE
FACILITY NUMBER: 425850335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2024
Section Cited
CCR
87705(k)(8)

1
2
3
4
5
6
7
87705(k)(8) Care of Persons with Dementia (k)...Requirements must be met…licensee to utilize delayed egress devices on exterior doors or perimeter fence gates: (8) Delayed egress...not substitute for trained staff...numbers meet...supervision needs of all residents...
1
2
3
4
5
6
7
The licensee will submit a written plan describing how they will ensure protocols for residents who require additional supervision while in care and the update of resident care plans to reflect wandering/elopement behaviors. Submit proof to CCL by 7/29/2024.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Based on record review and interview Licensee failed to have trained staff in sufficient numbers to supervise R1 to address multiple elopements by R1 causing injury on 6/19/24, which posed 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2