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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801876
Report Date: 04/27/2021
Date Signed: 04/27/2021 12:49:36 PM



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
02/03/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210203135538
FACILITY NAME:ATRIA GRAND OAKSFACILITY NUMBER:
565801876
ADMINISTRATOR:BRIAN LARIOSFACILITY TYPE:
740
ADDRESS:2177 E THOUSAND OAKS BLVDTELEPHONE:
(805) 370-5400
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY:140CENSUS: 84DATE:
04/27/2021
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Brian Larios TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility has not promptly provided resident's records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith conducted a subsequent complaint investigation to deliver the findings for the allegation above. The LPA met with Executive Director Brian Larios and explained the reason for the visit. During a 2/10/2021 visit, the LPA interviewed the Executive Director and requested documents. In addition, the LPA interviewed a representative from Atria’s legal team on 2/10/2021 at 11:01am, and interviewed staff on 4/7/2021 at 9:41am.

Regarding the allegation, it was alleged that the facility did not promptly relinquish requested documents to the authorized legal representative of Resident #1 (R1). Records review and interviews confirmed that a request to receive R1’s facility record was sent to this facility on May 22, 2020. On June 5th, the licensee sent an encrypted USB of records to R1’s authorized legal representative. However, on November 10, 2020, it was indicated that the USB did not include all of R1’s Medication Administration Records (MARs). As such, on 12/23/2020, the licensee sent additional MARs to R1’s authorized legal representative.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20210203135538
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: 04/27/2021
NARRATIVE
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After further review, it was discovered the delivery of documents from 12/23/2020 failed to pertain all the requested MARs. The licensee sent over additional documents to the legal representative on 2/17/2021. However, the community admitted that they were unable to relinquish all of the MARs from R1’s facility file.

Based on the investigation, there is sufficient evidence to support the claim that the facility was unable to promptly relinquish R1’s facility file in a timely manner. The original request was made on May 22, 2020 and the licensee relinquished the documents approximately nine months later. In addition, the facility was unable to relinquish the file in its entirety. 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, today's reports and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210203135538
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: 04/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2021
Section Cited
CCR
87468.2(a)(19)
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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
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The Administrator has agreed to do the following:
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 4/29/2021.
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This requirement is not met as evidenced by: Based on interview and records review, the licensee did not comply with the section cited above, as it took the licensee approximately nine months to relinquish R1’s facility file, which poses a potential personal rights risk to the 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3