565801876-6-10-2023-29-AS-JAPL-CSULYH-20230616091021

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801876
Report Date: 06/10/2023
Date Signed: 06/10/2023 12:55:08 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/09/2023 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20230209134721

FACILITY NAME:	ATRIA GRAND OAKS		FACILITY NUMBER:	565801876
ADMINISTRATOR:	BRIAN LARIOS		FACILITY TYPE:	740
ADDRESS:	2177 E THOUSAND OAKS BLVD		TELEPHONE:	(805) 370-5400
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY:	140	CENSUS: 78	DATE:	06/10/2023
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Brian Larios		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Staff has not promptly provided resident's records

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena arrived unannounced at 11:10 a.m. to conduct a subsequent visit to deliver the findings for the allegation listed above. The LPA met with Executive Director (ED) Brian Larios and explained the reason for the visit.

On 02/17/2023, Licensing Program Analyst (LPA) Sandra Urena arrived unannounced at 10:15 a.m. to conduct an initial complaint investigation for the allegation listed above. The LPA met with Executive Director (ED) Brian Larios and explained the reason for the visit. During the visit, the LPA interviewed the Executive Director. The ED stated they would contact the facility's Support Center/Corporate Office to gather additional information about the documents requested for R1.

Continues on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230209134721

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GRAND OAKS	FACILITY NUMBER: 565801876
	VISIT DATE: 06/10/2023

NARRATIVE

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On the allegation that, ‘Staff has not promptly provided resident's records’, the complainant’s concern is that they have requested records from the facility pertaining to Resident #1(R1) and the facility has failed to provide the requested records in a timely manner. To investigate the allegation, the LPA interviewed the ED on 02/17/2023 about the records requested by the complainant. The ED stated that records pertaining to residents who have left the facility are maintained at the corporate office. The ED stated that they would communicate with the corporate office to gather additional information for the documents requested and would inform the LPA once they received the records. During today’s visit the LPA asked the ED if the records requested by the complainant had been received from the corporate office. The ED stated that all records pertaining to R1 have already been provided to the complainant. No additional documents were found when the ED sent the request to the corporate office.

Based on the investigation, there is sufficient evidence to support the claim that the facility was unable to promptly provide R1’s facility file in a timely manner. The original request was made on 01/26/2023, via a letter which was faxed to Atria Grand Oaks listing the records requested: Resident Notes, Resident Functional Needs Assessment, and Medication Administration Records (MARs). The licensee failed to relinquish the records as of 06/10/2023. Whereas Medication Administration Records (MARs) are not a required document under licensing, it is a form utilized by this community and thus shall be relinquished upon written consent from the resident or the resident’s designated representative,

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D).

Exit interview conducted with facility representative. The reports and appeal rights were reviewed and issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230209134721

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GRAND OAKS	FACILITY NUMBER: 565801876
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/16/2023 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	87468.2(a)(19) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records... records shall be provided within two (2) business days. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	1. Submit a Statement of Understanding, detailing how the community will maintain compliance as it relates to the retention and relinquishing of requested resident files. Submit Statement to CCL by 06/19/2023.
	8 9 10 11 12 13 14	Based on interview and records review, the licensee did not comply with the section cited above, as the licensee did not provide R1’s additional missing documentation requested on 2/17/23, which poses a potential personal rights risk to the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2023

LIC9099 (FAS) - (06/04)

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