Inspection Reports for Atria Grand Oaks
2177 E Thousand Oaks Blvd, Thousand Oaks, CA 91362, United States, CA, 91362
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with several complaint investigations deemed unsubstantiated. The facility’s most recent report from August 20, 2025, identified minor issues with occasional undercooked food and some dining room wear, but no citations were issued. More serious findings occurred earlier, including substantiated physical abuse by staff in late 2024 and a $10,000 civil penalty issued in July 2025 for that abuse. Other notable issues involved staffing shortages in dining and housekeeping in 2022, uneven flooring posing safety risks, and delays in providing resident records, but these were addressed over time. Recent reports show improvement in compliance and safety, although isolated technical violations remain.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 128
Capacity: 140
Deficiencies: 2
Aug 20, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Deficiencies (2)
| Description |
|---|
| Food was reportedly undercooked on specific occasions. |
| Dining room tables and chairs had buildup and worn varnish causing a sticky appearance. |
Report Facts
Capacity: 140
Census: 128
Number of chairs refinished: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Eden Tolentino | Executive Director | Facility administrator met during inspection and interviewed |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 128
Capacity: 140
Deficiencies: 1
Jul 31, 2025
Visit Reason
Unannounced inspection to follow up on an investigation of a self-reported incident of physical abuse by facility staff against a resident.
Findings
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.
Complaint Details
Investigation of a complaint regarding physical abuse of resident (R1) by facility staff was substantiated, resulting in a civil penalty.
Deficiencies (1)
| Description |
|---|
| Violation of California Code of Regulations (CCR) 87468.1(a)(3) Personal Rights of Residents in All Facilities related to physical abuse of a resident. |
Report Facts
Civil penalty amount: 10000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Remon Pagels | Executive Director | Met with Licensing Program Analyst during inspection and acknowledged receipt of appeal rights. |
| Angela Barutyan | Licensing Program Analyst | Conducted the unannounced inspection and investigation follow-up. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Annual Inspection
Census: 125
Capacity: 140
Deficiencies: 0
Mar 19, 2025
Visit Reason
The visit was an unannounced required annual inspection conducted by Licensing Program Analysts to assess compliance with health, safety, and regulatory standards.
Findings
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.
Report Facts
Resident rooms observed: 10
Restrooms observed: 10
Resident records reviewed: 9
Personnel records reviewed: 6
Residents interviewed: 7
Staff interviewed: 4
Medication reviews: 3
Fire extinguisher last serviced: Jan 28, 2025
Fire alarm/sprinkler system last tested: Jul 9, 2024
Fire drill last conducted: Feb 26, 2025
Emergency evacuation drill last conducted: Feb 27, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eden Tolentino | Executive Director | Met with Licensing Program Analysts during inspection and assisted with facility tour |
| Brian Larios | Administrator/Director | Named as facility administrator/director |
| Emily Peraldi | Licensing Program Analyst | Conducted inspection and signed report |
| Angela Barutyan | Licensing Program Analyst | Conducted inspection |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 140
Deficiencies: 0
Mar 19, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding the allegation that facility staff do not maintain facility walkways free from hazards.
Findings
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.
Complaint Details
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.
Report Facts
Facility capacity: 140
Census: 125
Outdoor passageway width: 37
Outdoor passageway width: 60
Number of residents interviewed: 7
Number of staff interviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Eden Tolentino | Executive Director | Facility representative interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 140
Deficiencies: 0
Jan 29, 2025
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Facility capacity: 140
Resident census: 119
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the investigation and inspection visit |
| Eden Tolentino | Executive Director | Met with Licensing Program Analyst during the visit |
| Brian Larios | Administrator/Director | Facility administrator named in the report header |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 140
Deficiencies: 0
Nov 21, 2024
Visit Reason
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).
Findings
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.
Complaint Details
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.
Report Facts
Medication destruction dates: Medications destroyed on 8/25/2023, 10/3/2023, 1/17/2024, and 1/25/2024
Capacity: 140
Census: 116
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eden Tolentino | Executive Director | Met with Licensing Program Analyst during investigation |
| Brian Larios | Administrator | Facility administrator named in report header |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 119
Capacity: 140
Deficiencies: 1
Nov 12, 2024
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility did not comply with the requirement to protect residents from punishment, humiliation, intimidation, abuse, or other punitive actions, as evidenced by Staff #1 physically abusing Resident #1. | Type A |
Report Facts
Capacity: 140
Census: 119
Plan of Correction Due Date: Nov 19, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Larios | Administrator/Director | Interviewed during the investigation and named in the report |
| Eden Tolentino | Executive Director | Met with Licensing Program Analyst during inspection and interviewed |
| Kelly Dulek | Licensing Program Analyst | Conducted the subsequent case management visit and authored the report |
| Kristin Heffernan | Licensing Program Manager | Named as supervisor and licensing program manager in the report |
Inspection Report
Complaint Investigation
Census: 117
Capacity: 140
Deficiencies: 0
Oct 30, 2024
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 140
Census: 117
Response time: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation |
| Brian Larios | Administrator | Facility administrator mentioned in report |
| Eden Tolentino | Executive Director | Met with Licensing Program Analyst during investigation |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 140
Deficiencies: 0
Oct 16, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding the allegation that residents are not being provided with transportation.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 140
Census: 101
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the complaint investigation |
| Kristin Heffernan | Licensing Program Manager | Named in report signature and oversight |
| Brian Larios | Administrator | Facility administrator named in report |
| Eden Tolentino | Interim Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 140
Deficiencies: 1
Oct 16, 2024
Visit Reason
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.
Findings
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.
Complaint Details
The visit was conducted in conjunction with a complaint visit (Complaint Control # 29-AS-20241011153018).
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| One staff member did not have a criminal record clearance and one staff member did not have a criminal record clearance transfer. | Type A |
Report Facts
Civil penalty amount: 1000
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Barutyan | Licensing Program Analyst | Conducted the Case Management - Deficiencies visit and complaint investigation |
| Eden Tolentino | Executive Director | Stated that staff without clearance will not be scheduled until clearance is obtained |
| Brian Larios | Administrator/Director | Named as facility administrator/director |
| Kristin Heffernan | Licensing Program Manager/Supervisor | Named as Licensing Program Manager and Supervisor |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 140
Deficiencies: 0
May 21, 2024
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 140
Census: 116
Days for return to work after positive COVID test: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zabel Chochian | Licensing Program Analyst | Conducted the complaint investigation and visit |
| Brian Larios | Administrator | Facility administrator met during investigation |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 109
Capacity: 140
Deficiencies: 0
Mar 20, 2024
Visit Reason
The visit was a required unannounced annual inspection to ensure compliance with Title 22 Regulations and assess health and safety conditions at the facility.
Findings
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.
Report Facts
Rooms toured: 10
Residents interviewed: 5
Staff interviewed: 4
Resident files reviewed: 10
Staff files reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Larios | Executive Director | Met with Licensing Program Analysts during the inspection. |
| Teresa Camara | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Martha Arroyo | Licensing Program Analyst | Conducted the inspection. |
| Desaree Perera | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 140
Deficiencies: 0
Feb 14, 2024
Visit Reason
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.
Findings
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.
Complaint Details
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.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Larios | Executive Director | Interviewed during the investigation and contacted to conduct the visit. |
| Christine Yee | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 140
Deficiencies: 1
Jun 10, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff had not promptly provided a resident's records.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide Resident #1's records promptly as required by CCR 87468.2(a)(19), which mandates residents have prompt access to review all their records within two business days. | Type B |
Report Facts
Capacity: 140
Census: 78
Deficiency due date: Jun 16, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Urena | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brian Larios | Executive Director | Facility representative interviewed during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Plan of Correction
Census: 120
Capacity: 140
Deficiencies: 1
Feb 7, 2023
Visit Reason
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.
Findings
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.
Complaint Details
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.
Deficiencies (1)
| Description |
|---|
| Maintenance and Operation deficiencies related to floor repairs on the second and third floors. |
Report Facts
Civil penalties amount: 1100
Civil penalties amount: 700
Penalty daily rate: 100
Penalty days: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the unannounced Plan of Correction inspection. |
| Brian Larios | Administrator | Facility administrator met during the inspection. |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 140
Deficiencies: 0
Feb 7, 2023
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 140
Census: 120
Staff count overnight shift: 1
Staff count overnight shift: 2
Date complaint received: Jul 1, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Brian Larios | Executive Director | Facility administrator met during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 140
Deficiencies: 0
Feb 7, 2023
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Resident interviews: 11
Staff interviews: 7
Response time (minutes): 86
Response time (minutes): 93
Response time (minutes): 13.5
Housekeeping service gap (weeks): 3
Capacity: 140
Census: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Brian Larios | Executive Director | Met with Licensing Program Analyst during investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Annual Inspection
Census: 118
Capacity: 140
Deficiencies: 1
Jan 27, 2023
Visit Reason
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.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Swimming pool was observed accessible to residents in care, which poses an immediate health and safety risk. |
Report Facts
Civil penalty amount: 500
Water temperature range: 111.6
Water temperature range: 117
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and signed the report |
| Brian Larios | Executive Director | Met with Licensing Program Analyst during the inspection |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Plan of Correction
Census: 124
Capacity: 140
Deficiencies: 1
Dec 9, 2022
Visit Reason
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.
Findings
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.
Complaint Details
Inspection was due to deficiencies observed during the investigation of complaint control # 29-AS-20220610141057.
Deficiencies (1)
| Description |
|---|
| Maintenance and Operation deficiency related to flooring repairs not completed as required. |
Report Facts
Civil Penalties days: 11
Civil Penalty amount per day: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the unannounced Plan of Correction inspection. |
| Brian Larios | Administrator | Facility administrator involved in communication regarding the plan of correction. |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 140
Deficiencies: 1
Oct 28, 2022
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that the facility had mold.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Mold observed in the conference room, basement common restrooms, and on vents near the dining room, posing a potential health and safety risk to residents. | Type B |
Report Facts
Capacity: 140
Census: 124
Plan of Correction Due Date: Nov 18, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brian Larios | Executive Director | Facility administrator met during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 140
Deficiencies: 1
Oct 28, 2022
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel were insufficient in numbers and competence to provide necessary services to meet resident needs in dining and housekeeping departments. | Type B |
Report Facts
Staffing levels: 3
Staffing levels: 5
Staffing levels: 6
Staffing levels: 2
Staffing levels: 3
Staffing levels: 5
Staffing levels: 4
Staffing levels: 2
Staffing levels: 3
Deficiencies cited: 1
Plan of Correction Due Date: Nov 4, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brian Larios | Executive Director | Met with Licensing Program Analyst during investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
Inspection Report
Follow-Up
Census: 124
Capacity: 140
Deficiencies: 1
Oct 28, 2022
Visit Reason
The inspection was an unannounced Case Management - Deficiencies visit conducted due to deficiencies observed during the investigation of complaint control #29-AS-20220610141057.
Findings
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.
Complaint Details
Inspection was triggered by deficiencies observed during the investigation of complaint control #29-AS-20220610141057.
Deficiencies (1)
| Description |
|---|
| Flooring is uneven, which poses a potential health and safety risk to residents in care. |
Report Facts
Capacity: 140
Census: 124
Plan of Correction Due Date: Nov 28, 2022
Extension Deadline: Dec 28, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection. |
| Brian Larios | Administrator | Facility administrator met during the inspection. |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 140
Deficiencies: 1
Jul 11, 2022
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility locked exterior doors from the inside at night, preventing residents from leaving without staff assistance, violating personal rights. | Type A |
Report Facts
Capacity: 140
Census: 88
Plan of Correction Due Date: Jul 12, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brian Larios | Administrator | Facility administrator who met with the Licensing Program Analyst and agreed to submit a plan of correction |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 88
Capacity: 140
Deficiencies: 1
Jun 20, 2022
Visit Reason
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.
Findings
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.
Complaint Details
The complaint was substantiated based on observations and resident interviews confirming safety hazards due to uneven flooring.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Flooring is uneven with holes on the second and third floors, posing a potential health and safety risk to residents. | Type B |
Report Facts
Capacity: 140
Census: 88
Deficiencies cited: 1
Plan of Correction Due Date: Jul 5, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brian Larios | Administrator | Facility administrator involved in the investigation and agreed to submit plan of correction |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 140
Deficiencies: 0
May 6, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that the facility was malodorous and that facility equipment was in disrepair.
Findings
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.
Complaint Details
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.
Report Facts
Complaint Control Number: 29-AS-20220503103617
Capacity: 140
Census: 114
Visit start time: 09:00 AM
Visit end time: 10:40 AM
Date complaint received: May 3, 2022
Plumbing service date: Apr 4, 2022
Plumbing follow-up service date: Apr 30, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brian Larios | Executive Director | Facility Administrator met during the investigation and involved in addressing the complaint |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 108
Capacity: 140
Deficiencies: 1
Mar 4, 2022
Visit Reason
The inspection was an unannounced required annual visit with an emphasis on infection control practices and procedures.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Water temperatures registered above 120 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care. |
Report Facts
Deficiency due date: Mar 7, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Larios | Executive Director | Met with Licensing Program Analyst and informed of the reason for the visit |
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 140
Deficiencies: 0
Oct 12, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that residents were being forced to stay in their rooms.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 140
Census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kristin Heffernan | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Marco Perez | Maintenance Director | Met with the Licensing Program Analyst during the inspection |
| Carmy Jerome | Administrator | Administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 140
Deficiencies: 1
Apr 27, 2021
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide prompt access to resident records as required by CCR 87468.2(a)(19), taking approximately nine months to relinquish the resident's file. | Type B |
Report Facts
Census: 84
Total Capacity: 140
Deficiency Count: 1
Plan of Correction Due Date: Apr 29, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brian Larios | Administrator | Facility administrator involved in the investigation and interview |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the licensing program and signed the report |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 140
Deficiencies: 0
Apr 7, 2021
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Capacity: 140
Census: 84
Complaint control number: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Brian Larios | Executive Director | Met with Licensing Program Analyst during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 140
Deficiencies: 0
Apr 7, 2021
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Facility capacity: 140
Resident census: 84
Complaint control number: 29-AS-20200909161931
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Brian Larios | Executive Director | Met with Licensing Program Analyst during investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report as Licensing Program Manager |
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