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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800366
Report Date: 09/06/2022
Date Signed: 09/06/2022 03:34:01 PM


Document Has Been Signed on 09/06/2022 03:34 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:SARAH DODDFACILITY TYPE:
740
ADDRESS:405 HODENCAMP RDTELEPHONE:
(805) 373-0606
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:207CENSUS: 117DATE:
09/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sarah DoddTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management – Incident visit at 1:00pm. The LPA met with Executive Director (ED), Sarah Dodd and explained the reason for the visit. The purpose of this visit is to investigate an incident submitted to the Department by the facility regarding Resident #1 (R1), stating that Staff #1 (S1) punched them in the right calf area of their leg. Entrance interview.

During today’s visit, the LPA conducted a plant tour to ensure there are no immediate health and safety concerns and interviewed the Administrator and R1 between 1:15pm and 2:30 pm. At 1:45 pm., LPA conducted a resident file review and obtained copies of pertinent documents relevant to the investigation. Further investigation is required prior to issuing findings.

Exit interview conducted. A copy of the report was emailed to the ED.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
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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