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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801876
Report Date: 11/12/2024
Date Signed: 11/12/2024 02:02:22 PM

Document Has Been Signed on 11/12/2024 02:02 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 GRAND OAKSFACILITY NUMBER:
565801876
ADMINISTRATOR/
DIRECTOR:		BRIAN LARIOSFACILITY TYPE:
740
ADDRESS:2177 E THOUSAND OAKS BLVDTELEPHONE:
(805) 370-5400
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY: 140CENSUS: 119DATE:
11/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:12 PM
MET WITH:Eden Tolentino, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent case management visit with the purpose of continuing the investigation into a self-reported incident. LPA arrived at the facility at 12:12PM and was greeted by front desk staff. LPA met with Executive Director (ED) Eden Tolentino at 12:16PM. Entrance interview conducted.

An incident report was received at the Woodland Hills Regional Office on 02/12/2024. Incident report indicated that on the night of 02/11/2024, Staff #1 (S1) admitted to another staff that S1 was frustrated with Resident #1 (R1) and that S1 had kicked R1. The document states that the incident was reported to Long Term Care Ombudsman and Ventura County Sheriff in addition to Community Care Licensing and the resident's responsible party.

LPA Christine Yee conducted an initial case management visit related to this incident on 02/14/2024 from 10:45AM to 03:05PM. During the initial visit, LPA Yee conducted an interview with Brian Larios, Executive Director at 11:38am, an attempted interview with R1 at 11:26am, telephone interview with Staff #3 at 1:38pm and attempted telephone interviews with S1 at 1:58pm and Staff #2 at 1:21pm. Video camera footage was reviewed at 12:48pm and a copy taken at 1:08pm. Copies of facility documents were collected throughout the visit. LPA Yee was informed that as a result of the incident, S1’s employment at the facility was terminated. During today’s subsequent visit, LPA Dulek conducted an interview with ED Tolentino at 12:20PM, reviewed and obtained copies of relevant documents, and briefly toured the facility with ED at 12:45PM. No immediate health and safety hazards were observed during facility tour.

LPA Dulek reviewed recorded video footage of the incident, which shows S1 pulling R1 by their hands and R1 falling to the ground. R1 then raises their feet and kicks at S1, then S1 kicks R1. S1 then picked up R1’s shoe and appears to hit R1 with their shoe before walking away down the hall, leaving R1 on the floor. LPA

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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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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 GRAND OAKS
FACILITY NUMBER: 565801876
VISIT DATE: 11/12/2024
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Dulek confirmed the facility conducted an internal investigation into the incident and as a result terminated S1’s employment effective 02/13/2024. LPA confirmed S1 is no longer associated to this facility in Guardian. Review of S1’s staff file did not contain additional write ups or performance concerns.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or CA Health and Safety Code. Failure to correct the deficiency may result in civil penalties. Executive Director was informed that at a later date, civil penalties might be assessed based on health and safety code 1569.49(f).

Exit interview was conducted with Executive Director. A copy of today’s report and appeal rights were reviewed and provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/12/2024 02:02 PM - It Cannot Be Edited


Created By: Kelly Dulek On 11/12/2024 at 12:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA GRAND OAKS
FACILITY NUMBER: 565801876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/19/2024
Section Cited
CCR
87468.1(a)(3)

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87468.1 Personal Rights of Residents in All Facilities (a) (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...interfering with daily living functions such as eating, sleeping, or elimination.
This requirement is not met as evidenced by:
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As a result of the incident, S1 was terminated. ED agreed to provide personal rights and abuse training to all current staff and provide proof of training to CCL by POC due date.
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The facility did not comply with the above cited section, as based on review of video footage, S1 is seen physically abusing R1, which posed an immediate 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
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