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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561703345
Report Date: 04/15/2021
Date Signed: 04/16/2021 10:16:31 AM

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:TREACY VILLAFACILITY NUMBER:
561703345
ADMINISTRATOR:EVANGELINE MICHAYLUKFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA RDTELEPHONE:
(805) 644-1292
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:49CENSUS: 24DATE:
04/15/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH: Evangeline (Joy) MichaylukTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Joann Rosales and Ashley Morgan conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20210414134413.

During today’s investigation, the LPAs were greeted by Staff #1 (S1). Upon review of the associations list, it was discovered that S1 was not cleared to work at this facility. The LPAs checked the online caregiver background check portal Guardianto further confirm that S1 was not associated to this community. S1 informed the LPAs that they had been working at the facility for approximately two months. When the LPAs inquired as to whether S1 was associated, S1 stated that their status was 'Pending'.

During today’s investigation, a physical plant tour was conducted at 11:14am with Administrator Evangeline (Joy) Michayluk. At 11:27am, slats of wood of various sizes were observed outside. At 11:38am, the Laundry room was unlocked, and detergent was accessible. At 11:39am, a storage closet was found to be unlocked, and cans of paint and a hedge trimmer were accessible. At 11:44am, the staff lounge was found to be unlocked, and a bottle of shampoo/body wash was accessible.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).



Exit interview conducted, today's report and appeal rights were reviewed and issued via email. Signatures will be signed virtually and emailed to the Department. Civil penalties assessed.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
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: TREACY VILLA
FACILITY NUMBER: 561703345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2021
Section Cited

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87355(e)(1) Criminal Record Clearance. 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: Obtain a California clearance or a criminal record exemption as required by the Department.
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This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as the licensee did not ensure that S1 cleared and associated prior to allowing S1 to work, which poses an immediate health and safety risk to residents in care.
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Civil penalty of $500 will be assessed today.
Type A
04/16/2021
Section Cited

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87705(f)(2) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as the licensee did not ensure that chemicals and disinfectants were inaccessible, which poses an immediate health and safety risk to residents in care.
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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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2021
LIC809 (FAS) - (06/04)
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