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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800366
Report Date: 02/10/2023
Date Signed: 02/10/2023 01:25:59 PM


Document Has Been Signed on 02/10/2023 01:25 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:ATRIA HILLCRESTFACILITY NUMBER:
565800366
ADMINISTRATOR:ADAM SYNCHEFFFACILITY TYPE:
740
ADDRESS:405 HODENCAMP RDTELEPHONE:
(805) 373-0606
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:207CENSUS: 105DATE:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Executive Director-Brian LariosTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos arrived unannounced to conduct a required annual visit. The LPA met with Executive Director Brian Larios and informed them of the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations.

Kitchen: At the time of the visit, there was a sufficient supply of two-day perishable and seven-day nonperishable food. The menu was posted, and the facility offers daily specials and a standard selection at every meal. Appliances appeared to be in operable condition. Bin used to store sugar was broken allowing for potential contamination if left exposed.

Common Areas: The facility is a three-story building. There are resident rooms on all three floors, units are designated for assisted living residents on all three floors and a separate unit on the second floor is designated for residents in the memory care unit. There is a central entry point for universal screening and temperature checks. Staff were observed wearing appropriate face coverings throughout the visit. There was hands-free hand sanitizer interspersed throughout the common grounds.

There were no obstructions and/or tripping hazards observed. The facility maintains a comfortable temperature at 73 degrees Fahrenheit. The fire extinguishers were charged and last serviced 2/25/2023. Smoke detectors and carbon monoxide detectors are tested yearly and were operable at the time of the visit.

At the time of the visit, a cabinet in the memory care food service kitchen was observed to be disrepair and the cabinet beneath the aquarium in the memory care unit was also observed to be in disrepair.

Activities: Planned activities are offered, and the activity schedule was posted, and is provided to the residents on a weekly basis. Activity rooms and common spaces appeared clean and in good repair.

...Continued on LIC 809-C...

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
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 02/10/2023 01:25 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
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: 02/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one staff (S1) was not associated to the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/11/2023
Plan of Correction
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The licensee agreed to do the following:
1. Associate staff and submit proof to CCL no later than 2/11/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


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
VISIT DATE: 02/10/2023
NARRATIVE
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Rooms: The LPA toured randomly selected rooms in both the memory care and assisted living unit. Rooms appeared clean, well kept, and appropriately furnished.

Restrooms: Restrooms on all floors were clean and sanitary. Restrooms were fully stocked with supplies, and hand hygiene signs were observed in all restrooms. The LPA observed one room in the memory care unit that had a broken towel rack. The water temperature was tested on all floors and water temperature ranged from 117.8-119.8 degrees Fahrenheit.

Outside areas: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There was an enclosed patio for residents whom reside in the memory care unit on the second floor.

File Review: The LPA conducted a file review of staff associations to the facility. The LPA identified one staff did not have their association appropriately transferred. The LPA informed the Executive Director. A civil penalty in the amount of $500 is assessed for this violation.

Infection Control: The community has an adequate supply of Personal Protection Equipment (PPE) and can obtain additional supplies. The community's cleaning protocol is sufficient. This facility has records of staff and resident vaccinations. The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. Staff are up to date regarding guidelines pertaining screening recommendations, masking requirements of staff and visitors, and reporting procedures. The community's policies and procedures pertaining to infection control were adequate.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. Civil penalties assessed. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/10/2023 01:25 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
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: 02/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as the kitchen drawer in the memory care unit needs repair, the cabinet under the aquarium in the memory care unit needs repair, the towel rack in the shower for room # 242 in memory care was broken and needs repair, a bin in the main kitchen on the 1st floor containing sugar was broken, which poses a potential health and safety risk to residents in care.
POC Due Date: 02/17/2023
Plan of Correction
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The licensee agreed to do the following:
1. Repair identified items. Submit proof to CCL no later than 2/17/2023.

Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4