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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801876
Report Date: 02/07/2023
Date Signed: 02/07/2023 01:09:54 PM

Unsubstantiated


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
07/01/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220701165224
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: 120DATE:
02/07/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Brian LariosTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Resident cannot access their bathroom sink.
Facility personnel are not sufficient in numbers to meet resident needs.
Staff are not allowing resident to leave the facility for outings.
Staff are not meeting resident's hygiene and/or grooming needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a subsequent complaint visit. The LPA met with Executive Director Brian Larios and explained the reason for the visit.

On 11/16/2022, the LPA toured the facility, obtained documents, and conducted staff and resident interviews from 9:30 a.m. - 11:00 a.m. On 01/27/2023, the LPA interviewed six (6) residents from 10:20 a.m. - 2:00 p.m. Additional staff interviews were conducted on 02/03/2023 at 11:50 a.m. and 2:13 p.m. On 02/06/2023, the LPA interviewed seven (7) staff from 1:20 p.m. - 3:30 p.m. Today, the LPA interviewed residents five (5) residents from 9:35 a.m. – 10:50 a.m. The LPA also obtained and reviewed additional documentation.
Unsubstantiated
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: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
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 4
Control Number 29-AS-20220701165224
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: 02/07/2023
NARRATIVE
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Regarding the allegation: Resident cannot access the bathroom sink

It was alleged that for residents that utilized a motorized scooter, residents were unable to access their bathroom sink to wash their hands or to care for their personal hygiene needs. The LPA interviewed residents whom utilized a motorized scooter and residents communicated no concerns regarding their ability to use their bathroom sink. Staff also denied claims that any resident whom utilized a motorized scooter had mentioned concerns with an inability to use their bathroom sink. Staff noted that in the case of Resident #1 (R1) they had removed R1’s bathroom door to allow better access for R1’s motorized scooter. The LPA also interviewed R1, whom utilized a motorized scooter while residing in the facility, and R1 denied claims that they were unable to access the bathroom sink. During the course of the investigation, the LPA was unable to obtain sufficient information to determine that resident(s) could not access the bathroom sink. Based on the information obtained, this allegation is deemed Unsubstantiated at this time.


Regarding the allegation: Facility personnel are not sufficient in numbers to meet resident needs

It was alleged that the facility is understaffed because if residents fall at night, staff are unable to lift the resident and call 9-1-1 for a lift assist. It was an indication that the facility required additional staff at night, versus depending on 9-1-1. It was also alleged that the facility was understaffed because the facility did not allocate staff to accompany residents on outings for residents that are deemed unable to leave unassisted. This is addressed in a separate allegation. Lastly, insufficient staff was reported in the dining room, yet this was addressed in complaint #29-AS-20220610141057 and deficiencies were issued on 10/28/2022.

The investigation revealed an instance where Resident #1 (R1) suffered a fall overnight and staff were unable to assist with lifting R1 up from the floor, which led to R1 being on the floor for an extended period of time. The LPA interviewed the staff whom responded to R1 requiring a lift assist during the overnight/NOC shift, and communicated that they were unable to lift R1 on their own and as a result, they called 9-1-1 for a lift assist. Staff admitted they were the only person the assisted living side and mentioned that whereas there was a staff on the memory care side, they were unable to leave the memory care residents unattended. Staff interviews claimed that at night, if a resident is on the ground, unless the resident is able to assist with the lift, staff will call 9-1-1 for lift assistance for the safety of the resident and the staff.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20220701165224
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: 02/07/2023
NARRATIVE
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The challenge is that the facility is at the mercy of the responsiveness of the emergency personnel, as one cannot determine how long it may take for emergency personnel to respond to a lift assist.

A review of staff schedules indicated that in December 2022, the community has one (1) care staff for the assisted living community during the overnight shift primarily on Saturdays, Sundays, and Mondays. Yet staff schedules demonstrated that for from Tuesday-Friday, there are generally two (2) care staff on shift for the assisted living community during the overnight shift. Resident interviews supported claims that in general, residents believe that staff were responsive regarding care if assistance is required at night. A review of incident reports confirmed that the facility staff have occasionally utilized 9-1-1 for lift assist for the safety of the resident and the staff person, regardless of staff persons on shift. Whereas this is the policy of Atria to call 9-1-1 for a lift assist, it is not an immediate indication of insufficient staffing.

Based on the information obtained, there is insufficient evidence to support the allegation of insufficient staffing as it pertains to residents that fall during the overnight shift. Per interviews, it is Atria policy to not support the use of two-person assist and believe the utilization of emergency personnel for lift assist is beneficial for all parties involved. This allegation is deemed Unsubstantiated at this time.



Regarding the allegation: Staff are not allowing resident to leave the facility for outings.

It is alleged that R1 cannot attend community outings, and it was alleged to be a violation of their personal rights. Interviews and records review show that R1’s physician’s report dated 6/29/2021 indicates that R1 is unable to leave the facility unassisted due to physical limitations. R1 claimed that their physician did not agree with the claim, but the LPA was unable to identify documentation from R1's physician to confirm that R1 was able to attend community outings. Staff interviews stated that for those whom are unable to leave unassisted, the resident would need to be accompanied by a companion or a family member. Staff confirmed that, at the time, they did not have additional staff to accompany those whom cannot leave unassisted. Yet, a review of Atria’s Program Plan did not indicate that a staff person is designated nor required to accompany a resident on a community outing if they are deemed unable to leave unassisted. Staff claim that they were abiding by the orders as determined by R1’s physician as to whether R1 can leave unassisted. The LPA advised management to consider the circumstances regarding residents whom would like to participate in community outings and do not have the means to provide a 1:1 companion or family member.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20220701165224
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: 02/07/2023
NARRATIVE
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Whereas some staff claimed that the above-mentioned residents with outing restrictions could potentially attend the scenic drives where a resident does not leave the bus, the internal policy can be viewed as limiting. Based on the information obtained, there is insufficient evidence to support the claim that staff are not allowing resident(s) to leave the facility for outings. Residents whom cannot leave unassisted as per their physician’s report are able to leave the facility for outings; however, the facility is not required or mandated to provide the 1:1 companion in those cases. This allegation is deemed Unsubstantiated at this time.


Regarding the allegation: Staff are not meeting resident’s hygiene and/or grooming needs

it was alleged that staff are unable to meet the hygiene and grooming needs of residents in this facility, as it was communicated that staff cannot clip resident nails. Staff interviews revealed that only a podiatrist is able to clip resident nails, and it was communicated that a podiatrist comes to the facility on a regular basis. The LPA reviewed documentation that confirmed that a podiatrist comes to the facility weekly. Staff claimed that if they observe that the resident’s nails are long or require attention, they would inform management and a referral to the podiatrist could be made. Interviews with R1 confirmed claims that R1 was aware that staff could not clip their fingernails and toenails, but communicated that staff assisted with other aspects of hygiene and grooming. Further investigation confirmed that depending on the insurance that a resident has, they are able to use the facility podiatrist and the resident can file a claim with their insurance to cover the benefit, or the resident would have to pay out of pocket. The use of the facility podiatrist is not included in basic services. During the course of the investigation, the LPA was unable to obtain sufficient information to determine that staff were not meeting the resident hygiene and or grooming needs. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4