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 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.

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.

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

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.

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 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 was terminated following the incident.

The investigation confirmed that Staff #1 physically abused Resident #1 by kicking and hitting them with a shoe, posing an immediate health, safety, and personal rights risk. 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 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 triggered by a complaint (Complaint Control # 29-AS-20241011153018).

During the visit, two staff members were found without the required criminal record clearance or clearance transfer. One staff member was placed on leave until clearance is obtained. A deficiency was cited related to this violation, and civil penalties of $1000 were issued.

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 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.

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.

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.

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

The facility was previously cited for maintenance issues regarding floor repairs that had not been completed as required. The Plan of Correction was met at the time of this inspection, but civil penalties were issued for delays in compliance.

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.

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

The inspection found that floor repairs required due to observed holes and dips had not begun as planned. The licensee failed to submit a building layout indicating repair sections or request an extension by the deadline. Civil penalties were issued for non-compliance.

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 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 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 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.

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 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 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.