<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801876
Report Date: 03/04/2022
Date Signed: 03/04/2022 10:59:47 AM


Document Has Been Signed on 03/04/2022 10:59 AM - 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:BRIAN LARIOSFACILITY TYPE:
740
ADDRESS:2177 E THOUSAND OAKS BLVDTELEPHONE:
(805) 370-5400
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY:140CENSUS: 108DATE:
03/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Brian LariosTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit, which has an emphasis on infection control practices and procedures. The LPA met with Executive Director Brian Larios and informed them of the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations.

Kitchen: The facility had a sufficient supply of two-day perishable and seven-day nonperishable food at the time of the visit. Food is prepared based on the resident’s diets. The menu was posted and the facility offers an alternate menu. Facility uses Cisco Foods for food deliveries, and delivery takes place twice a week. Snacks and beverages are available for residents.

Common Areas: The facility is a three-story building, and it also has a basement level. There are resident rooms on all three floors, units are designated for assisted living residents on all three floors and a separate unit on the first floor is designated for residents in the memory care unit. Upon entry to the facility, there is a central entry point for symptom screening and temperature checks for residents, staff, and visitors. Staff were observed wearing appropriate face coverings throughout the visit. In addition, the LPA observed hands-free hand sanitizer interspersed throughout the common grounds.

There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature at 73 degrees Fahrenheit. There are fire extinguishers throughout the facility, which were charged and last serviced 2/2022. Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging residents in group activities. All activity rooms and common spaces appeared clean and in good repair.

Outside areas: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is a locked pool with appropriate gating. Parking is available for residents and visitors.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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 5


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: 03/04/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Common Restrooms: The LPA observed common restrooms on all three floors. Whereas hand-washing signs were observed on the first floor, the LPA informed the Executive Director that signs promoting good hand hygiene should be placed in all common restrooms in the facility. However, all restrooms were fully stocked with soap and paper towels. During today’s visit, the LPA tested water temperature on all three floors, and the temperature averaged between 139.7 – 146.6 degrees Fahrenheit. The Executive Director informed the LPA the facility was actively working on this issue and a vendor was coming out to fix the building’s boiler.

Infection Control: During today’s visit, the LPA spoke with the Executive Director regarding the community's infection control practices. The LPA encouraged the Executive Director to create a centralized location with COVID-19 signs that promoted hand hygiene, physical distancing, and cough/sneeze etiquette. The community has an adequate supply of Personal Protection Equipment (PPE) and is able to obtain additional supplies. The community's cleaning protocol is sufficient. This facility has records of staff and resident vaccinations. If needed, the facility has the capacity to designate isolation zones if there is a confirmed case of COVID-19. The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The community's policies and procedures pertaining to infection control were adequate.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

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

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/04/2022 10:59 AM - 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 GRAND OAKS

FACILITY NUMBER: 565801876

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as water temperatures registered above 120 degrees Fahrenheit, which poses an immediate health and safetyrisk to persons in care.
POC Due Date: 03/07/2022
Plan of Correction
1
2
3
4
The Administrator will send the LPA documentation regarding to the repair of the facility boiler no later than 3/7/2022. Thereafter, facility will send a five-day temperature log to demonstrate that the temperature is regulated within range. Temperature log will be sent to the LPA no later than 3/14/2022
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

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: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5