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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200243
Report Date: 08/13/2024
Date Signed: 08/13/2024 06:27:22 PM

Document Has Been Signed on 08/13/2024 06:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:VENTURA HILLS MANORFACILITY NUMBER:
079200243
ADMINISTRATOR/
DIRECTOR:		JES CARL BATACANFACILITY TYPE:
735
ADDRESS:1520 VENTURA AVENUETELEPHONE:
(510) 236-1001
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 14CENSUS: 12DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:MARYBETHLEAH LOCSIN, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
07:07 PM
NARRATIVE
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On 08/13/2024 at 1:45pm, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced annual 1-year required inspection. LPA met with Jonathan Guevarra, Caregiver and explained the purpose of the visit. Administrator, Marybeth Locsin, arrived at 2:15pm. The administrator currently holds a certificate (#6066872735) that expires on 07/19/2025. The facility’s fire clearance was approved for two (2) ambulatory and 12 non-ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, storage room, and back yard. The facility consists of 12 bedrooms (12) one is occupied by staff and a total of five (5 ) bathrooms which one (1) is designated staff bathroom. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 107.0 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguishers were last services on 12/6/2023, 04/02/2024 and 11/6/2023. Fire drill last conducted 05/19/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: VENTURA HILLS MANOR
FACILITY NUMBER: 079200243
VISIT DATE: 08/13/2024
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Continued from LIC809.

six (6) staff records were reviewed, and all staff have first aid certification. six (6) clients' records reviewed, current, and complete. LPA reviewed P&I.

The following forms to be updated and submitted to CCLD by 08/23/2024:
  • Liability insurance.
  • Surety Bond
  • LIC500 (Personnel Record)
  • Client Roster
  • LIC308 (Designation of facility Responsibility)
  • LIC400 Affidavit Regarding Client/Resident Cash Resources
  • Updated facility sketch.


LPA observed the following deficiencies:
  • At 2:15PM, LPA observed drawers in room numbers 2, 3, 5, 6, and 7 off track.
  • At 2:30PM, LPA observed a leak under the kitchen sink.
  • At 2:40PM, LPA observed mouse droppings in room# 7 bathroom drawers.
  • At 2:45PM, LPA observed fence located in the back and side yard is falling and in disrepair.
  • At 2:49PM, LPA observed tires, fender, drainage pipes located on the side yard. At 2:55PM, LPA observed an exit boarded up from the outside in a storage area that is boarded up inside the building.

The deficiencies was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/13/2024 06:27 PM - It Cannot Be Edited


Created By: Carol Fowler On 08/13/2024 at 05:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VENTURA HILLS MANOR
FACILITY NUMBER: 079200243

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in clients bedroom drawers in disrepair, leak under the kitchen sink, mouse droppings in drawers, fence in disrepair, tires, fender and drainage pipe in the side yard. which poses a potential health and safety risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Administrator agreed to repair or replace the dressers that are off track submit photos to the Department by the POC date. Have leak under the kitchen sink repaired and submit a copy of the invoice to the Department by the POC date. Contact a pest control company to schedule an inspection for mice/rats and send a copy of the invoice and inspection report to CCL by POC date.
Have fence repaired and submit photos to the Department by the POC date. Remove tires, fender and drainage pipe from side yard and submit photos to the Department by POC date.
Type B
Section Cited
CCR
80086(a)(c)
80086 Alterations to Existing Building or New Facilities(a) Prior to construction... all licensees shall notify licensing...proposed change.(c) Prior to construction or alterations, state or local law requires...a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in not notifying CCLD with building alterations in boarding up an exit which poses a potential health and safety risk to persons in care.
POC Due Date: 08/27/2024
Plan of Correction
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Administrator agrees to submit a form LIC 200 and a updated facility sketch and/or a building permit to the Department by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024


LIC809 (FAS) - (06/04)
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