197690039-8-23-2023-29-AS-ECAS-CUYVQR-20230823163845

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197690039
Report Date: 08/23/2023
Date Signed: 08/23/2023 04:39:19 PM

Document Has Been Signed on 08/23/2023 04:39 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LA VENTANA TREATMENT PROGRAMS		FACILITY NUMBER:	197690039
ADMINISTRATOR:	DIAHANN KLEIN		FACILITY TYPE:	772
ADDRESS:	779 BRIAR CLIFF ROAD		TELEPHONE:	(805) 371-5700
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 6		CENSUS: 4	DATE:	08/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Sharon Volner Cheif Clinical Officer		TIME COMPLETED:	04:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 10:15 a.m. The LPA was greeted by staff and informed them of the reason for the visit. Chief Clinical Officer/LMFT Sharon Volner and Director of Operations/LVN Wendy McCain arrived shortly thereafter.

The LPA along with the Director of Operations toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. Additional food supplies and emergency food supply is kept in the attached garage. The LPA observed the entrance closet where all medications and sharps are kept locked and inaccessible. Client files are locked and inaccessible in the staff office. BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three (3) designated client rooms that are shared. There was a linen closet in the hallway with extra towels and linens. BATHROOMS: There are three (3) bathrooms for client use. Client bathrooms are clean and sanitary and in operating condition. Bathrooms are sufficiently stocked with hand liquid soap and paper towels. Bathrooms were measured for hot water, the first bathroom measured at 118.9 degrees Fahrenheit at 11:09 a.m., the second bathroom measured at 109.4 degrees Fahrenheit at 11:11 a.m., and the third bathroom measured at 111.2 degrees Fahrenheit at 11:13 a.m.

…Report Continued on LIC 809C…

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LA VENTANA TREATMENT PROGRAMS	FACILITY NUMBER: 197690039
	VISIT DATE: 08/23/2023

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…Report Continued from LIC 809...

GROUNDS: There is a covered patio area with patio furniture including a table and chairs for client use. Facility has one (1) fenced gate that self-latches with clear passageways for emergency exit use. No large bodies of water accessible to clients during time of visit. COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for client use. Three (3) fire extinguishers were observed to be last serviced on 11/22/2022. The facility maintained a comfortable temperature of 73 degrees. Smoke detector(s) and carbon monoxide detector were tested at 11:30 a.m. and operational at the time of the visit. The LPA observed required postings throughout the common spaces. There is a laundry room that contains a chemical cabinet and cleaning supplies that is locked and inaccessible to clients. The garage is attached and is used as a gym room and staff office. RECORDS: Client records review began at 12:20 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. During record review the LPA observed that eight (8) staff on schedule were not associated to the facility. The deficiency was discussed with the Director of Operations and associated all staff at the time of the visit. MEDICATIONS: Medications review began at 1:15 p.m.; medications are centrally stored and locked in a closet at the entrance of the facility. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA obtained the following documents: Personnel Report, Client Roster, Liability Insurance.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Civil were assessed for associations.

Exit interview conducted. Appeal Rights Discussed. A copy of the report was provided via email.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/23/2023 04:39 PM - It Cannot Be Edited

Created By: Elsie Campos On 08/23/2023 at 04:22 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LA VENTANA TREATMENT PROGRAMS	FACILITY NUMBER: 197690039
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

81019(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as eight (8) staff were identified not to be assocaited to the facility which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/23/2023
	Plan of Correction
1 2 3 4	The Licensee agreed to the following: 1. Associate all staff to the facility. Plan of correction met at the time of the visit. Civil Penalties assessed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Elsie Campos

LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC809 (FAS) - (06/04)

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