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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800366
Report Date: 07/29/2022
Date Signed: 07/29/2022 11:53:07 AM


Document Has Been Signed on 07/29/2022 11:53 AM - 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:SARAH DODDFACILITY TYPE:
740
ADDRESS:405 HODENCAMP RDTELEPHONE:
(805) 373-0606
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:207CENSUS: DATE:
07/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Sarah DoddTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced CASE MANAGEMENT- INCIDENT visit to the above facility to investigate an incident that occurred on 7/17/2022. LPA met with Executive Director (ED), Sarah Dodd. Entrance interview conducted.

On 7/22/2022, LPA Arroyo spoke with the ED regarding an incident of Elopement for Resident #1 (R1). on 7/17/2022. It was reported that on 7/17/2022 at 7:30 p.m., R1 entered the elevator in the memory care unit along with a private companion of another resident. R1 then proceeded to follow the private companion out of the elevator and exited the facility. Interviews revealed that although there is a front desk clerk every day between the hours of 8am to 8pm, R1 was still able to walk out of the facility unnoticed. Around 8:20 p.m., a staff member noticed R1 wandering in the parking lot and walked them back into the facility. The LPA confirmed with R1's family member that the facility reported the incident the following day after the incident had ocurred. A review of R1's records revealed that per R1’s Physician’s Report dated 6/19/2022, R1 is not able to leave the facility unassisted. However, R1 was found outside of the facility alone and unassisted by facility staff. ED provided LPA with documentation showing the memory care staffs have been in-serviced training regarding safety and elopement protocols. Based on the information obtained during the investigation staff failed to supervise R1 on 7/17/2022 as R1 eloped from the facility.

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. Appeal Rights discussed. Today’s reports were reviewed and emailed to the Executive Director.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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 07/29/2022 11:53 AM - 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: 07/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2022
Section Cited

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87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by:
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Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which poses an immediate health and safety risk to persons 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 ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
LIC809 (FAS) - (06/04)
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