ATRIA GRAND OAKS

Official classification

Type A

Official code

87307(e)(2)(A)

Regulation authority

CCR

What the official deficiency says

(e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (2) Fishponds, wading pools, hot tubs, swimming pools, or similar larger bodies of water. (A) The licensee shall ensure that the bodies of water specified above are inaccessible through fencing, covering, or other means when not in active use by residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as the outdoor swimming pool was accessible to residents in care which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/20/2026 Plan of Correction The latching mechanism for the pool gate was repaired during the visit. POC is cleared.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as the facility had no record of a current and active liability insurance policy which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/26/2026 Plan of Correction ED stated they will provide proof of liability insurance to CCL by the due date.

Official classification

Type B

Official code

87468.2(a)(19)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the rights listed...residents...shall have all of the following personal rights: (19)To have prompt access to review all of their records...Photocopied records shall be provided within two (2) business days... This requirement is not met as evidenced by: Based on interview and record review, licensee did not comply with the section cited as Resident #1's records were not provided within 2 business days and medical records were not provided to an authorized representative. This poses a potential personal rights risk to persons in care.

Official plan of correction

ED stated they will submit a signed statement of understanding of the section cited to CCL by the due date. ED will also provide the medical records to R1's authorized representative and submit proof.

Deadline recorded: Mar 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(a)(3)

Regulation authority

CCR

What the official deficiency says

87224(a)(3) Failure of the resident to comply with general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 was issued an eviction notice for violating house rules, however all parties involved did not believe R1’s behavior was abusive, which posed a potential personal rights risk to persons in care.

Official plan of correction

Executive Director agreed to write a statement of understanding regarding evictions and send to CCL by POC due date.

Deadline recorded: Jan 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: The facility did not comply with the above cited section, as based on review of video footage, S1 is seen physically abusing R1, which posed an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

As a result of the incident, S1 was terminated. ED agreed to provide personal rights and abuse training to all current staff and provide proof of training to CCL by POC due date.

Deadline recorded: Nov 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Based on record review, the licensee did not comply in that one (1) staff member did not have a criminal record clearance and one (1) staff member did not have a criminal record clearance transfer which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Facility associated staff without a criminal record transfer during the visit. ED stated that the staff without clearance is going on leave effective today and will not be working until obtaining clearance.

Deadline recorded: Oct 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(19)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(19) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records... records shall be provided within two (2) business days. This requirement is not met as evidenced by: Based on interview and records review, the licensee did not comply with the section cited above, as the licensee did not provide R1’s additional missing documentation requested on 2/17/23, which poses a potential personal rights risk to the residents in care.

Official plan of correction

1. Submit a Statement of Understanding, detailing how the community will maintain compliance as it relates to the retention and relinquishing of requested resident files. Submit Statement to CCL by 06/19/2023.

Deadline recorded: Jun 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(e)

Regulation authority

CCR

What the official deficiency says

(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above, as the swimming pool was observed accessible to residents in care, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 01/28/2023 Plan of Correction The Administrator has agreed to do the following: 1. Secure the pool. Send out a memo to all staff, communicating protocol regarding pool usage and ensuring it is locked at all times. Inform CCL when this has taken place, but must take place no later than 1/28/2023, end of day. Immediate civil penalty of $500 assessed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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: Based on observation and interview, the licensee did not comply with the section cited above as the flooring is uneven, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Licensee has agreed to do the following: 1. The licensee will send a layout of the building, indicating the flooring sections that will require repair no later than 11/9/2022. 2. Repairs must be completed by 11/28/2022. a request for an additional thirty day extension must be submitted before 11/28/2022.

Deadline recorded: Nov 28, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews and record review, licensee failed to ensure that the facility had an adequate number of staff to meet the residents needs in dining and housekeeping departments, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to the following: 1. Submit a Staffing Plan by 11/4/2022. Staffing Plan shall detail the efforts the licensee has employed to ensure adequate staffing in dining and housekeeping departments. Plan shall detail steps taken in response to call-outs.

Deadline recorded: Nov 4, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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.

Deadline recorded: Nov 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents ... shall have all of the following personal rights:(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above, as the exterior doors to the facility are locked from the inside, which poses an immediate personal rights risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Submit a statement, detailing how the community will regain compliance with Regulation 87468.1(a)(6). Submit statement to CCL no later than 7/12/2022, end of day.

Deadline recorded: Jul 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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: Based on observation and interview, the licensee did not comply with the section cited above as the flooring is uneven, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Submit a Plan of Action to CCL, documenting the proposed plan in repairing the flooring (ie. holes) on the second and third floor. A reasonable timeline to repair the holes must be proposed. Plan of Action shall be submitted no later than 7/5/2022. Approved plan shall also be shared with residents at this facility.

Deadline recorded: Jul 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above, as water temperatures registered above 120 degrees Fahrenheit, which poses an immediate health and safetyrisk to persons in care.

Official plan of correction

POC Due Date: 03/07/2022 Plan of Correction The Administrator will send the LPA documentation regarding to the repair of the facility boiler no later than 3/7/2022. Thereafter, facility will send a five-day temperature log to demonstrate that the temperature is regulated within range. Temperature log will be sent to the LPA no later than 3/14/2022

Official classification

Type B

Official code

87468.2(a)(19)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(19) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records... records shall be provided within two (2) business days This requirement is not met as evidenced by: Based on interview and records review, the licensee did not comply with the section cited above, as it took the licensee approximately nine months to relinquish R1’s facility file, which poses a potential personal rights risk to the residents in care.

Official plan of correction

The Administrator has agreed to do the following: 1. Submit a Statement of Understanding, detailing how the community will maintain compliance as it relates to the retention and relinquishing of requested resident files. Submit Statement to CCL by 4/29/2021.

Deadline recorded: Apr 29, 2021. A deadline is not proof that correction was completed.