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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800366
Report Date: 08/26/2021
Date Signed: 08/26/2021 04:46:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ATRIA HILLCRESTFACILITY NUMBER:
565800366
ADMINISTRATOR:SARAH DODDFACILITY TYPE:
740
ADDRESS:405 HODENCAMP RDTELEPHONE:
(805) 373-0606
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:207CENSUS: 114DATE:
08/26/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Sarah DoddTIME COMPLETED:
04:45 PM
NARRATIVE
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On 8-26-2021, Licensing Program Analyst (LPA), Martha Guzman Chavez conducted an unannounced Case Management-Other visit to the above facility. LPA met with Administrator Sarah Dodd and Resident Services Coordinator, Carthel Mercado to discuss the serious illness/injury reporting requirement as per regulation 87211(a)(1)(D) Reporting Requirements. Entrance interview conducted.

During today’s visit, documents reviewed revealed unusual incent/injury reports occurred between 8-04-2021 (2), and 8-07-2021 were not submitted timely within the seven (7) days as they were received by CCL on 8-15-2021. Furthermore, on 8-16-2021, another unusual incident/injury report was received by CCL on 8-24-2021, marking it received on the 8th day. LPA advised Management that serious illness/injuries are required to be reported to CCL within seven (7) days of the incident(s) as required by California Code of Regulations.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. A copy of the report will be emailed to the administrator. Appeal Rights issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA HILLCREST
FACILITY NUMBER: 565800366
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2021
Section Cited

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87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency ... within seven days of the occurrence: Any incident which threatens the welfare, safety or health of any resident.

This requirement is not met as evidenced by:
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Based on interviews and documents received, Administrator failed to ensure the incident reports of four (4) residents during the period of two (2) weeks be received by CCL within 7 days of occurrence which poses a potential health & 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021
LIC809 (FAS) - (06/04)
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