565801876-6-20-2022-29-AS-JAPL-CKRQ64-20221101115253

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801876
Report Date: 06/20/2022
Date Signed: 06/20/2022 01:45:10 PM

Substantiated

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
06/10/2022 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20220610141057

FACILITY NAME:	ATRIA GRAND OAKS		FACILITY NUMBER:	565801876
ADMINISTRATOR:	BRIAN LARIOS		FACILITY TYPE:	740
ADDRESS:	2177 E THOUSAND OAKS BLVD		TELEPHONE:	(805) 370-5400
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY:	140	CENSUS: 88	DATE:	06/20/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Brian Larios		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is in disrepair

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial 10-day visit. The LPA met with Executive Director Brian Larios and explained the reason for the visit. Today, the LPA conducted a tour at 10:20 a.m., observed lunch service from 12:00 p.m. – 12:40 p.m., interviewed staff at 9:15 a.m. and 11:32 a.m., and spoke with residents at 10:30 a.m., 10:43 a.m., 10:50 a.m., and 10:59 a.m., and throughout lunch service from 12:42 p.m. – 1:00 p.m.

Regarding the above allegation, it was alleged that the flooring is uneven on the second and third floor. During the physical plant tour, the LPA observed several areas where there was a ‘hole’ or a noticeable dip in the flooring. Resident interviews confirmed that residents were worried about tripping and falling, as many residents ambulate with a walker or a wheelchair. Observations confirmed that the uneven surfaces pose a safety hazard to the residents. There is sufficient evidence to support the claim that the facility is in disrepair. This allegation is deemed Substantiated at this time. Pursuant to Title 22 Regulations, deficiencies were cited (refer to LIC 9099-D). Exit interview conducted, today's report and appeal rights were issued.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

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-20220610141057

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: 06/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/05/2022 Section Cited CCR 87303(a)	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:	1 2 3 4 5 6 7	The Administrator agreed to do the following: 1. Submit a Plan of Action to CCL, documenting the proposed plan in repairing the flooring (ie. holes) on the second and third floor. A reasonable timeline to repair the holes must be proposed. Plan of Action shall be submitted no later than 7/5/2022.
	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	Approved plan shall also be shared with residents at this facility.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3