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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800366
Report Date: 11/10/2022
Date Signed: 11/10/2022 03:53:38 PM


Document Has Been Signed on 11/10/2022 03:53 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:BRIAN A LARIOSFACILITY TYPE:
740
ADDRESS:405 HODENCAMP RDTELEPHONE:
(805) 373-0606
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:207CENSUS: 108DATE:
11/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:Brian LariosTIME COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Deficiencies visit at the facility due to a deficiency discovered during a complaint investigation.

On 11/10/2022, an interview with Administrator Brian Larios revealed the facility had a COVID-19 outbreak in August 2022 affecting approximately nine residents and one staff which was not reported to Community Care Licensing (CCL). The Administrator stated the outbreak was reported to Ventura County Public Health but the prior Administrator forgot to inform CCL.

The following deficiency was cited from the CA Code of Regulations. See LIC 809-D. Exit interview conducted. A copy of the report and appeal rights was issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
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 11/10/2022 03:53 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: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2022
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(2) Occurrences, such as..outbreaks..which threaten the...or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile..
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This requirement is not met as evidence by:
Based on interview, the licensee failed to comply with the section cited above, as the Administrator failed to report to CCL a COVID-19 outbreak which poses a potential health, safety, and personal rights 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: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
LIC809 (FAS) - (06/04)
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