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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801876
Report Date: 10/28/2022
Date Signed: 10/28/2022 02:47:14 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
10/26/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20221026161448
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
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Brian LariosTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility has mold
INVESTIGATION FINDINGS:
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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 physical plant tour from 10:10 a.m. – 11:10 a.m., and interviewed staff at 10:17 a.m., 10:47 a.m., 10:50 a.m., 11:00 a.m., and 11:20 a.m., and 11:40 a.m.

It was alleged that the facility had mold. The LPA toured all common spaces in the facility on the first floor, second floor, third floor, and in the basement level. Common spaces throughout the facility included: restrooms, bistro, library, dining/seating area, staff conference room, wellness center, medication rooms, activity rooms. The LPA observed a random selection of resident rooms on all three floors.

CONT 9099-C
Substantiated
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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20221026161448
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: 10/28/2022
NARRATIVE
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At 10:20 a.m., the LPA observed a black-like substance on the vents near the dining room, adjacent to the kitchen. At 10:30 a.m., the LPA toured the basement level of the facility. The LPA identified what appeared to be mold in the staff conference room. The LPA toured the two (2) common restrooms on the basement level and observed a black-like substance, which appeared to be mold, in both restrooms. The LPA again toured conference room and the two (2) restrooms found in the basement area with the Maintenance Director at 11:05 a.m., whom confirmed that the panel in the staff conference room would need to be removed in order to properly treat the mold.

Based on the information obtained, there is sufficient evidence to support the claim that the facility failed to keep the facility free of mold. 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.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20221026161448
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: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2022
Section Cited
CCR
87303(a)
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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:
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The Licensee agreed to do the following: Treat the mold observed in the bathrooms, vents, and and staff conference room. If repairs are required, communicate the time frame in which the mold will be removed. Mold removal must take place within the next three weeks. Submit proof of completion no later than 11/18/2022.
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Based on observation, the licensee did not comply in the section cited above, as mold was observed in the conference room and a black like substance was observed in the basement common restrooms and on the vents near the dining room, which poses a potential health and safety 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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3