Inspection Reports for Atria Grand Oaks

The inspection was an unannounced complaint investigation triggered by allegations received on 2025-07-23 regarding inadequate food service and cleanliness issues at the facility.

The investigation found that the food was occasionally undercooked and the dining room tables and chairs had some buildup and wear, but there was no direct impact or danger to residents. These issues were considered technical violations with no citations issued.

The complaint alleged that on 2025-07-17, the dinner meal was not prepared properly with undercooked meat and potatoes, and concerns about cleanliness of dining room tables and chairs. The complaint was substantiated but determined to be a technical violation with no citations.

Unannounced inspection to follow up on an investigation of a self-reported incident of physical abuse by facility staff against a resident.

The Department concluded that a civil penalty is warranted for physical abuse based on surveillance video evidence showing staff physically abusing a resident. A $10,000 civil penalty is being issued.

Investigation of a complaint regarding physical abuse of resident (R1) by facility staff was substantiated, resulting in a civil penalty.

The visit was an unannounced required annual inspection conducted by Licensing Program Analysts to assess compliance with health, safety, and regulatory standards.

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.

An unannounced complaint investigation was conducted regarding the allegation that facility staff do not maintain facility walkways free from hazards.

The investigation found no current safety concerns or deficiencies related to the allegation. The outdoor walkways were maintained in good repair and not obstructed, and residents and staff did not report safety issues. The allegation was deemed unsubstantiated due to insufficient evidence.

The complaint alleged that a rug outside the front entrance and outdoor walkways posed safety hazards. The rug had been removed due to prior concerns. Measurements of passageways showed adequate width for walker use. Interviews and observations did not corroborate the allegation. The complaint was unsubstantiated.

The visit was conducted as an unannounced case management incident investigation regarding a self-reported incident of suspected abuse that occurred on 2025-01-22.

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

The complaint involved suspected abuse of Resident #1 by an unknown staff member who allegedly dragged the resident to the bathroom. 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 on the resident.

An unannounced complaint investigation visit was conducted in response to an allegation that facility staff destroyed residents' personal belongings, specifically over-the-counter supplements and/or medications of resident 1 (R1).

The investigation found that facility staff did destroy some of R1's medications and supplements; however, these destructions were authorized based on physician orders indicating which medications were discontinued or had dosage changes during the period when the facility was managing R1's medications. Therefore, the allegation was deemed unsubstantiated.

The complaint alleged that facility staff destroyed residents' personal belongings, specifically R1's over-the-counter supplements and medications. The allegation was investigated and found unsubstantiated based on physician orders and medication management records.

The visit was conducted as a subsequent case management investigation into a self-reported incident involving staff abuse of a resident, originally reported on 02/12/2024.

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 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 inspection was conducted as a complaint investigation following an allegation that staff do not ensure signal system calls are answered promptly for residents in care.

The investigation found that residents generally receive timely responses to call signals, with staff assigned to groups of residents and call logs reviewed daily. Although one resident reported a fall without their pendant, overall there was insufficient evidence to substantiate the allegation, which was deemed unsubstantiated.

The allegation was that staff do not ensure signal system calls are answered promptly. The complaint was investigated and deemed unsubstantiated due to lack of preponderance of evidence.

The inspection was conducted as an unannounced complaint investigation regarding the allegation that residents are not being provided with transportation.

The investigation found that although the facility currently lacks a full-time driver, transportation is being provided by staff and management using facility vehicles. Transportation sign-up sheets, schedules, and resident interviews indicated that transportation needs are being met, and group outings are offered. The allegation was deemed unsubstantiated due to insufficient evidence of a violation.

The complaint alleged that residents were not being provided with transportation due to the absence of a regular driver. The allegation was unsubstantiated after investigation.

The visit was conducted as a Case Management - Deficiencies inspection in conjunction with a complaint investigation to issue a citation for a deficiency observed during the initial complaint investigation.

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

The visit was conducted as a complaint investigation following an allegation that staff were not following proper infection control requirements, specifically that staff who tested positive for COVID-19 were asked to continue working while still symptomatic.

The investigation found that facility staff followed proper infection control procedures, including return-to-work protocols after COVID-19 infection. Staff and residents denied the allegation, and the reporting party refused to cooperate. Due to insufficient evidence, the allegation was deemed unsubstantiated.

The complaint alleged that staff who tested positive for COVID-19 on 10/28/2023 were asked to continue working while symptomatic. Staff interviews and policy review confirmed adherence to infection control protocols, including a five-day return-to-work period after symptoms improve and no fever. The reporting party was uncooperative. The allegation was unsubstantiated.

The visit was a required unannounced annual inspection to ensure compliance with Title 22 Regulations and assess health and safety conditions at the facility.

The facility was found to be in compliance with regulations, with no health or safety hazards observed. The facility maintains a comprehensive disaster plan, conducts regular fire drills and inspections, and has adequate infection control measures. Resident rooms, common areas, restrooms, and outdoor areas were clean and well maintained. No deficiencies were cited during the inspection.

The visit was an unannounced 24-hour case management investigation of an incident reported on 2024-02-12 regarding alleged abuse of Resident #1 by Staff #1.

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.

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.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff had not promptly provided a resident's records.

The investigation found sufficient evidence that the facility failed to promptly provide Resident #1's records in a timely manner, violating Title 22 of the California Code of Regulations. The facility did not provide the requested records from 01/26/2023 until the date of the visit on 06/10/2023.

The complaint was substantiated. The allegation was that staff did not promptly provide resident records requested by the complainant. The investigation confirmed the facility failed to provide the requested records in a timely manner, posing a potential personal rights risk to residents.

An unannounced Plan of Correction inspection was conducted due to deficiencies observed during the investigation of complaint control #29-AS-20220610141057 related to maintenance and operation issues.

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.

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 inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-07-01 regarding multiple allegations about resident care and facility staffing at Atria Grand Oaks.

The investigation found insufficient evidence to substantiate the allegations that residents could not access their bathroom sinks, that staff numbers were insufficient to meet resident needs, that residents were not allowed to leave for outings, and that staff were not meeting residents' hygiene and grooming needs. The facility's policy to call 9-1-1 for lift assists during overnight falls was confirmed, and no deficiencies were cited.

The complaint included allegations that residents could not access their bathroom sinks, insufficient staffing to meet resident needs, restrictions on residents leaving for outings, and failure to meet hygiene and grooming needs. All allegations were investigated and deemed unsubstantiated based on interviews, document reviews, and observations.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-11-16 regarding allegations of inadequate staffing, inadequate food service, and improper rent increase at the facility.

The investigation found insufficient evidence to substantiate the allegations of inadequate staffing, inadequate food service, and improper rent increase. Residents reported some concerns, but the facility protocols and regulatory standards were followed, and no deficiencies were cited.

The complaint included allegations that the facility had inadequate staffing to meet residents' needs, staff did not provide adequate food service, and there was an improper rent increase. The investigation included interviews with residents and staff, document reviews, and observations. All allegations were deemed unsubstantiated due to insufficient evidence.

The Licensing Program Analyst Ashley Smith arrived unannounced to conduct a required annual visit to ensure the facility's compliance with Title 22 Regulations and to check for health and safety hazards.

The facility was generally found to be in compliance with health and safety standards, including clean and well-maintained rooms, adequate infection control measures, and proper supplies. However, a zero tolerance violation was cited due to the swimming pool gate being left open and accessible to residents, posing an immediate health and safety risk.

An unannounced Plan of Correction inspection was conducted due to deficiencies observed during the investigation of a complaint related to maintenance and operation issues with the flooring.

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

Unannounced complaint investigation visit conducted due to an allegation that the facility had mold.

The Licensing Program Analyst observed mold in multiple areas including vents near the dining room, staff conference room, and basement restrooms. The allegation of mold was substantiated and deficiencies were cited for failure to keep the facility clean, safe, sanitary, and in good repair.

The complaint alleging the presence of mold was substantiated based on observations during the unannounced visit. The facility failed to keep the premises free of mold, violating Title 22 regulations.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-06-10 regarding allegations of insufficient staffing, unsafe and uncomfortable environment for residents, and inadequate food service.

The allegation of insufficient staffing in dining and housekeeping was substantiated with evidence of staff shortages causing long wait times and reduced housekeeping services. The allegations that staff did not provide a safe and comfortable environment and did not provide adequate food service were unsubstantiated based on interviews and observations.

The complaint investigation was substantiated for insufficient staffing, specifically in dining and housekeeping departments. The allegations that staff did not provide a safe and comfortable environment and did not provide adequate food service were unsubstantiated.

The inspection was an unannounced Case Management - Deficiencies visit conducted due to 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.

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

An unannounced complaint investigation visit was conducted due to an allegation that the facility has fire hazards, specifically that doors are disabled at night preventing residents from leaving without staff assistance.

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

An unannounced complaint investigation visit was conducted due to an allegation that the facility is in disrepair, specifically concerning uneven flooring on the second and third floors.

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

The visit was an unannounced complaint investigation triggered by allegations that the facility was malodorous and that facility equipment was in disrepair.

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 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 inspection was an unannounced required annual visit with an emphasis on infection control practices and procedures.

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 inspection was conducted as a complaint investigation following an allegation that the facility did not promptly provide a resident's records to the authorized legal representative.

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 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 visit was an unannounced complaint investigation conducted in response to allegations received on 2020-03-09 regarding medication management, resident sleep interruptions, and privacy concerns at the facility.

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.

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 inspection was an unannounced complaint investigation triggered by allegations that facility staff did not provide for a resident's dietary needs and did not notify the resident's authorized representative of a change in condition.

The investigation found insufficient evidence to support the allegations. The facility provided dietary options consistent with residents' needs, although the resident sometimes chose foods outside their prescribed diet. The facility regularly updated the resident's authorized representative about changes in condition. Both allegations were deemed unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included failure to meet dietary needs and failure to notify the authorized representative of a change in condition. Evidence showed the facility met dietary requirements and regularly communicated with the authorized representative despite COVID-19 restrictions.

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