Atria Grand Oaks.

Licensing Program Analyst (LPA) Angela Barutyan arrived on July 31, 2025 for an unannounced inspection to follow up on an investigation of a self-reported incident by the facility. The LPA met with Remon Pagels, designated Executive Director. On November 12, 2024, the Department concluded an incident report investigation regarding the following incident: facility staff physically abused resident (R1). The licensee was cited for California Code of Regulations (CCR) 87468.1(a)(3) Personal Rights of Residents in All Facilities. At the time of the incident report investigation, the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for physical abuse. The Welfare and Institutions Code Section 15610.63 for physical abuse means (b) Battery, as defined in Section 242 of the Penal Code. This is evidenced by the facility surveillance video showing that the staff willfully committed violence against R1 by pulling R1 to the ground, kicking R1 and hitting R1 with R1’s shoe. Today, July 31, 2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as physical abuse in the amount of $10,000. Exit interview conducted. A copy of the report issued. Appeal rights provided. Remon Pagels and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.

Licensing Program Analysts (LPAs) Emily Peraldi and Angela Barutyan arrived at the facility unannounced to conduct a required annual visit. At 9:50 a.m., the LPAs met with staff and explained the reason for the visit. At 10:15 a.m., the Executive Director (ED) Eden Tolentino arrived at the facility. At 10:26 a.m., the LPAs, along with the ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards. The facility is a three-story building, with resident rooms on all three floors. Units are designated for assisted living residents on all three floors and a separate unit on the first floor is designated for memory care residents. KITCHEN: At 10:28 a.m., the LPAs observed the kitchen and dining area. Kitchen area remains inaccessible to residents. Knives are inaccessible to residents in care. Kitchen appliances are in operable condition. Chemicals and cleaning supplies were stored separately from the food and food preparation area. The facility has a sufficient supply perishable and nonperishable food. The menu was posted outside the dining area. Snacks and beverages are available for residents. BEDROOMS: The LPAs observed ten (10) randomly selected resident rooms throughout facility. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. RESTROOMS: The LPAs observed restrooms in ten (10) resident units and common area restrooms. All restrooms were fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was tested throughout the visit and measured within the required range. Continued on LIC 809-C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 COMMON AREAS: The LPAs observed common area to be relatively clean and properly furnished. The LPAs observed the fire extinguishers throughout the facility to be fully charged and last serviced on 01/28/2025. The facility's smoke alarms are hard wired, and the facility is equipped with sprinkler system. Fire alarm/sprinkler system was last tested on 07/09/2024 with the Ventura County Fire Protection District. Inside temperature was maintained at a comfortable level. OUTDOOR SPACE: The LPAs observed appropriate outdoor furniture with a covered shaded area for residents. There was an enclosed patio for residents whom reside in the memory care unit. There was a locked pool area with appropriate gating. No immediate concerns noted. ACTIVITIES: Planned activities are offered, and the activity schedule was posted. The activity schedules are distributed to the residents and are also located near the elevators for residents to pick up if needed. Activity rooms and common spaces appeared clean and in good repair. OTHER: Medications and first aid kits are located in locked medication rooms. There is also a mail room next to the receptionist area. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the janitor closets/maintenance closets. There are laundry rooms observed the second and third floor of the facility. FILES: Between 1:40 p.m. and 3:22 p.m., the LPAs conducted a file review for nine (9) residents and six (6) staff. The nine (9) resident records were reviewed for, but not limited to: care plans, medical assessments, admissions agreement, consent forms. Resident records were in order. Six (6) personnel records were reviewed for, but not limited to: health assessments, first aid/CPR training, and training documentation. Personnel files were in order. Facility fire drill was last conducted on 02/26/2025. Emergency evacuation drill was last conducted on 02/27/2025. The LPAs reviewed facility's Infection Control Plan and Emergency and Disaster Plan which was observed to be complete and updated. Starting at 2:05 p.m., the LPA conducted a review of medication and medication documentation with staff for three (3) residents and observed that medications were properly documented and assisted with as prescribed. No concerns or errors were observed. During the physical plant tour, the LPAs conducted interviews with seven (7) residents and four (4) staff. During the time of the visit, the LPAs obtained a copy of the liability insurance, resident roster and LIC 500 personnel report. No deficiencies cited. Exit interview conducted. A copy of the report was provided.

It was alleged that the rug outside of the front entrance of the facility and the outdoor walkways posed safety hazards to residents. Upon entry at 09:50AM, LPAs did not observe a rug by the front door entrance. Interviews conducted with staff and residents confirmed that there used to be a rug at the entrance, but it was removed due to several reports of the rug getting caught on resident walkers. It was further alleged that the outdoor passageways are too narrow and pose concerns for walker usage. LPAs observed the outdoor passageways which were maintained in good repair and not obstructed. Seven (7) out of seven (7) residents interviewed did not report any current safety concerns. At 01:57PM, LPA along with the Maintenance Director, measured the outdoor passageway by the side of the facility to be 37 inches, and at 01:59PM the outdoor passageway leading to the front of the facility to be 60 inches. The average walker measures around 23-28 inches. No concerns of the width of the passageways were noted. Staff interviewed did not have current physical plant safety concerns. LPAs did not observe any immediate safety concerns or deficiencies during the physical plant tour. Minor physical plant concern in the laundry room on the third floor is being addressed by the ED. LPAs had a conversation with the ED to ensure that all rugs in the facility shall have protective devices such as nonslip materials and to ensure that there are no tripping hazards throughout the facility. Based on LPAs’ observation, interviews, and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Facility staff do not maintain facility walkways free from hazards” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 10:32AM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 01/22/2025. Upon arrival, the LPA met with staff and Executive Director (ED) Eden Tolentino. Entrance interview conducted. During today’s visit, LPA Barutyan conducted a brief physical plant tour to ensure there are no health and safety hazards and conducted interviews with two (2) staff members and and one (1) resident. On 01/24/2025, the Department received two SOC 341s for suspected abuse of Resident #1 (R1) by an unknown staff member. Per the SOC 341, it was reported to Staff #1 (S1) that another staff member dragged R1 to the bathroom who then had to crawl back to their bed. ED reported the incident to Adult Protective Services (APS) and the Long-Term Care Ombudsman (LTCO) and informed R1’s responsible party. Ventura County Sheriff Officer conducted a visit on 01/24/2025 and determined the incident to be unfounded with no suspicion of crime. On 01/28/2025, the Department received an incident report for the incident. The incident report and SOC 341 stated that 911 was contacted when the suspected abuse was first reported on 01/24/2025. Paramedics conducted a full-body assessment and did not observe bruising, injuries, or rug burns on R1. R1 was not transported to the hospital. Facility management investigated the incident and interviewed AM, PM, and NOC shift staff, no concerns were noted. LPA interviewed R1 and no concerns were noted. Based on information obtained during the investigation, there is not sufficient evidence to prove a violation did occur. No citations issued. Copy of the report was provided.

(continued from LIC9099) R1 had a hospital stay starting on or about 6/22/2023. On 8/15/2023, R1's physician sent a new medical assessment to the facility indicating R1 could no longer store or manage their own medications. Facility staff removed all medications, including over-the-counter medications/supplements, from R1's room. Facility staff ensured they received orders from R1's physicians for all of the medications and supplements. Any medications that had a change of dose or were discontinued were destroyed. Medication destruction records show there were medications destroyed on 8/25/2023, 10/3/2023, 1/17/2024, and 1/25/2024, which included some over-the-counter supplements/medications. Records from R1's physician showed there were supplements that were discontinued between 11/20/2023 - 12/8/2023, including Vitamin B-12 and Folic Acid. Those supplements were destroyed. There were other medications which were discontinued or changed; those were also destroyed. On 1/22/2024, R1's physician completed a medical assessment indicating R1 was capable of storing and managing their own medications. On 2/1/2024, the facility completed a new Service Plan indicating R1 no longer required medication management. Records show all medications, including supplements, the facility was storing and managing for R1 were released to R1. Based on information obtained, the facility staff did indeed destroy some of R1's medications and over-the-counter supplements. However, R1's physician had submitted a list to the facility indicating which medications, including supplements, were discontinued or had a change in dosage. The destruction of these medications and supplements occurred during the period when the facility was managing R1's medications due to R1's physician stating the need for medication management. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and report issued.

stated that all pendants are inspected monthly to ensure functionality. Staff interviews revealed that staff are assigned a group of residents, however, if one staff is busy, another caregiver will assist the resident. According to staff, typical response time is under 15 minutes. Administrator stated that all call logs are reviewed daily and if response time is greater than 15 minutes, staff need to provide an explanation for the late response. LPA interviewed residents as well, who indicated the care they receive is good and response time is adequate. There was a resident interviewed who indicated they had fallen, but their pendant was not on their body and was not within reach at the time of the fall. So the staff were unaware the resident had fallen. LPA spoke with reporting party who indicated they personally had no concerns with the call times, but had heard from others that they had a problem. Residents interviewed, including those the reporting party identified, indicated there had been no recent concerns related to the call response system. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation " Staff do not ensure signal systems calls are answered promptly for residents in care" is deemed UNSUBSTANTIATED at this time . No citations issued. Exit interview conducted. A copy of today's report was provided.

It was alleged that residents are not being provided with transportation. The reporting party (RP) stated that the facility does not have a current regular driver to provide transportation. Interviews with staff and ED explained that the previous full-time driver was terminated in the beginning of August 2024. The activity directors and management have been providing transportation in the meantime. Staff #1 (S1) manages AM transportation while Staff #2 (S2) manages PM transportation, both with the four-passenger facility vehicle. Staff #3 (S3) works part-time and has a Class B driver’s license and is therefore able to drive the sixteen-passenger facility bus on Saturdays and Sundays. ED stated that they are receiving applications for the driver position opening and have a few interviews this week to fill the position. Furthermore, LPA reviewed and obtained transportation sign-up sheets which document names of resident’s transportation appointment, destination of address, and pick-up time. Time slots are in thirty-minute intervals. Staff stated that a 24–48-hour notice is requested of residents when they would like to schedule transportation. LPA observed the welcome brochure and transportation schedule stating that “transportation is limited to a 10-mile radius, rides must be booked 24-hours in advance or earlier, and priority will be allotted to appointments, shopping trips may be rescheduled if needed.” The transportation schedule also states that the facility will help residents obtain public transportation such as Uber/Lyft or Dial-A-Ride at the resident’s expense if transportation needs cannot be met within the policy. LPA also observed scheduled events such as church rides offered every Sunday at 08:15AM, scenic drives, food outings, and sign-up sheets for these group outings. File review of the facility’s plan of operation states that the facility will provide “assistance in arranging transportation for all residents to medical and dental care appointments, shopping and recreational facilities, and religious activities.” Assistance in arranging also includes helping residents book public transportation services not provided by the facility. Interviews with residents explained that there is no issue when it comes to booking the facility car and that management are providing transportation, but the bus has a shortage due to the license class required to drive the vehicle. Residents also stated that there are group social outings offered such as Christmas light viewing and possible road trips in the future. Based on interviews and record review, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Residents are not being provided with transportation” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of today's report was provided.

Allegation) Staff are not following proper infection control requirements. It was alleged that facility staff who tested positive for Covid on 10/28/2023 were asked to continue work a couple of day later even though staff were still having symptoms. Staff interviewed reported that the facility policy and procedures were followed during the outbreak. Staff denied allegation and stated that no one was asked to work following a positive test result. Staff stated that after five (5) days if symptoms are better and they have no fever they were cleared to work. Facility Infection Control procedures regarding employee screening and return to work protocols reviewed reflect that staff may return to work five (5) days after a positive test if symptoms are improving and fever free without any fever-reducing medication. According to the staff interviews they were never asked to work following a positive (COVID) test result or with any COVID related symptoms. Random residents interviewed expressed that facility staff maintain proper infection control procedures . Reporting party was contacted several times through the course of the investigation to determine the validity of the allegation however RP was not willing to speak with LPA. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff are not following proper infection control requirements” is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report provided.

Licensing Program Analysts (LPAs) Teresa Camara and Martha Arroyo arrived unannounced to conduct a required annual visit. LPAs met with Executive Director Brian Larios and explained the reason for the visit. LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. The facility has a comprehensive disaster plan. The facility conducts a full evacuation of the facility annually and conduct monthly fire drills. The facility uses Johnson Controls to inspect their fire suppression system with the last inspections being conducted in August 2023 and January 2024. The facility maintenance staff conducts monthly inspections of all smoke and carbon monoxide detectors with the last inspection being conducted on March 2024. Kitchen: At the time of the visit, there was a sufficient supply of perishable and nonperishable food. The facility also has an emergency supply of food and water. The menu was posted and copies are available near the elevators for residents to take. The facility offers daily specials and a standard selection at every meal. Appliances appeared to be in operable condition. Common Areas: The facility is a three-story building, and it also has a basement level. There are resident rooms on all three floors, units are designated for assisted living residents on all three floors and a separate unit on the first floor is designated for memory care residents. There were no obstructions and/or tripping hazards observed. The facility maintains a comfortable temperature. The rooms have separate thermostats so residents can adjust the temperature to their preference. The fire extinguishers were charged and last serviced January 2024. Both facility elevators were operating properly. There are three stairwells that all have emergency evacuation chairs. (continued on 809-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (continued from LIC809) Activities: Planned activities are offered and the activity schedule was posted. The activity schedules are distributed to the residents and they are also located near the elevators for residents to pick up if they need another copy. Activity rooms and common spaces appeared clean and in good repair. Rooms: LPAs toured ten randomly chosen rooms; two in memory care, four on the second floor and four on the third floor. Rooms appeared clean, well kept, with sufficient lighting and appropriately furnished. Restrooms: Restrooms on all floors were clean and sanitary. Restrooms were fully stocked with supplies. The hot water temperature was tested on all floors and ranged from 112.8 -117.6 degrees Fahrenheit. Outside areas: LPAs observed appropriate outdoor furniture with a covered shaded area for residents. There was an enclosed patio for residents whom reside in the memory care unit. There was a locked pool area with appropriate gating. Infection Control: The community has an adequate supply of Personal Protection Equipment (PPE) and can obtain additional supplies. The community's cleaning protocol is sufficient. The community's infection control plan is adequate. Records: LPAs reviewed ten resident files and ten staff files starting at 2:15 p.m.; all were complete. Medications were reviewed at 3:50 p.m. and appeared to be given as prescribed. Interviews: LPAs interviewed five residents and four staff; no concerns were noted. No deficiencies cited. Exit interview conducted and report issued to ED.

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced 24 hour case management visit to investigate the incident reported to the Department on 2/12/24 regarding Resident #1 being abused by Staff #1. LPA Yee initially met with Sarah Dodd, Community Business Director upon arrival. Brian Larios was contacted via telephone and he arrived at 11:25am to conduct the visit. The reason for today's visit was explained. On today's visit, LPA Yee conducted an interview with Brian Larios, Executive Director at 11:38am, an attempted interview with Resident #1 at 11:26am, telephone interview with Staff #3 at 1:38pm and attempted telephone interviews with Staff #1 at 1:58pm and Staff #2 at 1:21pm. Video camera footage was reviewed at 12:48pm and a copy taken at 1:08pm. Copies of facility documents were collected throughout the visit. Based on the information obtained during today's visit, additional interviews need to be conducted and other information collected before a final decision can be made and the appropriate course of action to be taken regarding the resolution of this incident. At this time, information was provided that Staff #1 is no longer employed at the facility and does not pose a further threat to Resident #1 while the investigation is being conducted. Exit interview was conducted.