Inspection Reports for
Atria Grand Oaks

The facility was generally found to be clean, well-maintained, and compliant with many regulations including kitchen safety, resident room conditions, and medication management. However, two deficiencies were cited: the outdoor swimming pool gate was found unlocked and accessible posing an immediate safety risk, and the facility lacked proof of current liability insurance. The pool gate latch was repaired during the visit and a civil penalty of $500 was issued for the accessible pool.

The complaint alleged that the facility issued an invalid eviction notice to Resident #1 for behavior on 08/30/2025. The investigation included interviews with residents, staff, and the Executive Director, and review of documents. The allegation was substantiated as the eviction notice was not supported by evidence of abuse. Resident #1 moved out on 12/11/2025 due to the eviction notice.

The investigation found that the eviction notice issued to Resident #1 was not supported by evidence of abusive behavior as alleged. Interviews with involved parties indicated the resident was upset but did not engage in verbal abuse. The allegation was substantiated based on the preponderance of evidence, and a deficiency was cited for failure to comply with facility policies regarding evictions.

The visit was complaint-related, following a self-reported incident of physical abuse by facility staff against resident R1. The Department substantiated the complaint and determined a civil penalty was warranted.

The Department concluded that a civil penalty is warranted for physical abuse based on evidence including facility surveillance video showing staff committing violence against a resident. A civil penalty of $10,000 was issued for the violation.

The facility was found to be in compliance with no deficiencies cited. Observations included clean and well-maintained resident rooms, restrooms, common areas, and outdoor spaces. Safety equipment was properly maintained and tested. Resident and personnel records were in order, and medication administration was properly documented with no errors.

The complaint involved suspected abuse of Resident #1 by an unknown staff member who allegedly dragged the resident to the bathroom, causing the resident to crawl back to bed. The incident was reported to Adult Protective Services and the Long-Term Care Ombudsman. The Sheriff's investigation found no suspicion of crime, and paramedics found no injuries.

The investigation found no sufficient evidence to prove a violation occurred. Paramedics assessed the resident with no injuries observed, and the Ventura County Sheriff determined the incident unfounded with no suspicion of crime. No citations were issued.

The visit was complaint-related, investigating a self-reported incident where Staff #1 admitted to kicking Resident #1. The incident was reported to the Long Term Care Ombudsman, Ventura County Sheriff, Community Care Licensing, and the resident's responsible party. Staff #1's employment was terminated and substantiated by video evidence.

The investigation confirmed that Staff #1 physically abused Resident #1 by kicking and hitting them with a shoe, as evidenced by video footage. Staff #1's employment was terminated as a result. No immediate health and safety hazards were observed during the facility tour.

The visit was conducted in conjunction with a complaint visit (Complaint Control # 29-AS-20241011153018).

The inspection found that one staff member did not have a criminal record clearance and another staff member did not have a criminal record clearance transfer, posing an immediate health, safety, and personal rights risk to persons in care. Civil penalties of $1000 were issued.

The facility was found to be in compliance with no deficiencies cited. The physical plant, disaster plan, fire safety systems, kitchen, common areas, rooms, restrooms, outdoor areas, infection control, records, and interviews with residents and staff all met regulatory standards.

The investigation was initiated due to a reported incident of abuse of Resident #1 by Staff #1. The substantiation status is not yet determined as further information is being collected.

Interviews were conducted with facility staff and attempts were made to interview Resident #1 and involved staff. Video footage was reviewed and facility documents were collected. Staff #1 is no longer employed at the facility and does not pose a further threat while the investigation continues. Additional information is needed before a final decision can be made.

Inspection was triggered by complaint control #29-AS-20220610141057. The complaint was substantiated as deficiencies were cited and penalties issued for failure to comply with the Plan of Correction.

The facility was previously cited for maintenance and operation deficiencies regarding floor repairs on the second and third floors. The Plan of Correction was met at the time of this inspection, but civil penalties were issued for delayed compliance. No additional deficiencies were cited.

The facility was generally found to be in compliance with health and safety regulations, including adequate food supply, clean and well-maintained rooms, proper infection control, and safety equipment. However, a zero tolerance violation was cited for an unlocked pool gate posing an immediate health and safety risk, resulting in a $500 civil penalty.

Inspection was due to deficiencies observed during the investigation of complaint control # 29-AS-20220610141057.

The facility was cited for maintenance deficiencies related to flooring repairs that had not been completed as required. The licensee failed to submit a layout indicating flooring sections needing repair or request an extension by the deadline, resulting in civil penalties being issued.

Inspection was triggered by deficiencies observed during the investigation of complaint control #29-AS-20220610141057.

The licensee was re-cited for failure to correct the previously identified deficiency related to uneven flooring, which poses a potential health and safety risk to residents. The facility was required to submit a plan and complete repairs by specified deadlines.

The inspection was triggered by deficiencies observed during the investigation of complaint control #29-AS-20220610141057. The licensee was previously cited on 06/20/2022 for maintenance issues related to flooring and had not begun repairs as of the inspection date.

The licensee was cited for maintenance and operation violations due to uneven flooring posing a potential health and safety risk. The flooring project to repair the deficiencies had not begun as previously planned, and the licensee was re-cited with a plan of correction and deadlines for completion.

The complaint was substantiated. It was confirmed that the facility locks doors at night, restricting residents' ability to leave, which is a personal rights violation.

The allegation was substantiated as staff locked the exterior doors from the inside at night, which is a violation of residents' personal rights. The facility was cited for deficiencies related to locking residents in and a plan of correction was required.

The complaint was substantiated based on observations and resident interviews confirming safety hazards due to uneven flooring.

The investigation confirmed that the flooring was uneven with holes and dips, posing a safety hazard to residents, many of whom use walkers or wheelchairs. The allegation was substantiated and deficiencies were cited.

The complaint was unsubstantiated. Allegations included a malodorous facility and equipment disrepair. The plumbing issue causing the odor was addressed by capping pipes connected to the salad bar, rendering it inoperable. No current odor was detected during the visit.

The investigation found insufficient evidence to substantiate the allegations. The salad bar was inoperable due to capped pipes to address a sewage smell, but no malodorous smell was detected during the visit. The Administrator made efforts to resolve the issue and plans to remove or replace the salad bar.

The facility was generally in compliance with health and safety regulations, including infection control, food supply, and physical plant safety. However, a deficiency was cited for water temperatures exceeding the regulated maximum, posing a health and safety risk.

The complaint alleged that residents were being forced to stay in their rooms. Interviews and document reviews revealed that residents were gently reminded to return to their rooms for safety, but no residents felt forced to stay. The facility provided exercise and social opportunities in doorways to maintain social distancing. No staff were observed raising their voice or physically returning residents to their rooms. The allegation was unsubstantiated.

The investigation found no health or safety hazards and concluded that although residents may not like staying in their rooms, there was insufficient evidence to substantiate the allegation that residents were being forced to stay in their rooms. The allegation was deemed unsubstantiated.

The complaint was substantiated. It alleged that the facility did not promptly provide requested resident records to the authorized legal representative. The investigation confirmed delays and incomplete records delivery.

The investigation found that the facility took approximately nine months to relinquish the requested resident's records and was unable to provide all Medication Administration Records (MARs) in the resident's file, constituting a violation of residents' personal rights.

The complaint investigation addressed three allegations: 1) staff not allowing a resident's authorized representative to dispense medication, 2) staff interrupting resident's sleep due to frequent room checks, and 3) facility staff not providing resident privacy. All allegations were found unsubstantiated based on interviews, document reviews, and facility policies.

The investigation found insufficient evidence to substantiate the allegations. The facility's medication management policy was followed, two-hour resident checks were conducted for safety and did not intentionally interrupt sleep, and staff provided privacy by asking permission before entering rooms. All allegations were deemed unsubstantiated.