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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801876
Report Date: 10/28/2022
Date Signed: 10/28/2022 02:43:00 PM


Document Has Been Signed on 10/28/2022 02:43 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:BRIAN LARIOSFACILITY TYPE:
740
ADDRESS:2177 E THOUSAND OAKS BLVDTELEPHONE:
(805) 370-5400
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY:140CENSUS: 124DATE:
10/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Brian LariosTIME COMPLETED:
03:00 PM
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 conducted an unannounced Case Management- Deficiencies inspection at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20220610141057.

During the initial visit conducted on 06/20/2022, the LPA observed several areas in which there appeared to be a ‘hole’ or a noticeable dip in the flooring. The licensee was cited for 87303(a) Maintenance and Operation, and the licensee required to communicate a plan of action regarding the floor repairs, as it was highlighted as an extensive project. On 07/01/2022, the Executive Director communicated a tentative plan that the repairs would begin in August or September of 2022. It was noted that the licensee planned to remove the carpet, refinish the subfloor, and place new flooring over the subflooring. As of today, the project has not begun.

Today, the licensee will be re-cited under 87303(a) Maintenance and Operation. The licensee will send a layout of the building, indicating the flooring sections that will require repair no later than 11/9/2022.

At this time, the licensee will have until 11/28/2022 to complete the project. If the licensee requires an additional thirty (30) day extension, the request for a thirty (30) days extension will need to be communicated before 11/28/2022.

At this time, if an extension is requested, the flooring project will need to be completed by 12/28/2022. Failure to correct the deficiencies may result in additional civil penalties due to failure to correct.

See 809-D for deficiency. 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: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022
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 2


Document Has Been Signed on 10/28/2022 02:43 PM - 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: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2022
Section Cited

1
2
3
4
5
6
7
87303(a) Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on observation and interview, the licensee did not comply with the section cited above as the flooring is uneven, which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2