<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561703345
Report Date: 06/11/2021
Date Signed: 06/11/2021 07:21:11 PM

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: 23DATE:
06/11/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Evangeline MichaylukTIME COMPLETED:
06:18 PM
NARRATIVE
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
This Case management visit was conducted to address the deficiencies noted during the Pre-licensing visit conducted on 6/11/21 for Ventura Villa Assisted Living #565850093.

During facility tour at 10:22 am LPA observed windex, glue, scissors, rubbing alcohol and room spray in an unlocked Administrators office. During facility tour at 10:48 am and 12:04 pm with staff Jennifer Sharma hot water temperature tested at 131.7 and 126 degrees Fahrenheit in resident bathrooms. During facility tour at 10:52 am LPA observed hair spray, shaving cream, 20 volume cream developer and concentrated bleach in an unlocked beauty salon accessible to residents. During facility tour starting at 11:00 am LPA did not observe mattress pads on any of the residents beds. During facility tour at 11:05 am LPA observed hair spray and hair conditioner, lotion and barrier cream in room #401's bathroom accessible to residents. During facility tour at 11:13 am LPA observed rust and mold in shower room floor and walls, shampoo and conditioner accessible to residents. During facility tour at 11:21 am LPA observed shower gel in the dining room accessible to residents. During facility tour at 11:36 am LPA observed a razor in room #411's shared bathroom accessible to residents. During facility tour at 11:44 am LPA did not observe 7 day supply of non-perishable fruit as the facility had 5 large cans of fruit. During facility tour at 11:53 am LPA observed a hole in the wall in room #101. During facility tour at 12:05 pm LPA observed a knife in room #105's refrigerator accessible to residents. During facility tour at 12:18 pm LPA observed deodorant in room #202's bathroom accessible to residents. During facility tour at 12:19 pm LPA observed shampoo in Shower room B.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Civil penalties assessed in the amount of $250.00
Exit interview conducted, todays reports, appeals rights were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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: 06/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2021
Section Cited

1
2
3
4
5
6
7
87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA's observations and record review, the licensee did not comply with the section cited above as a knife, razor and scissors were observed accessible to residents which posed an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
Type A
06/12/2021
Section Cited

1
2
3
4
5
6
7
87705 Care of Persons with Dementia (f)(2) 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.
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA's observations and record review, the licensee did not comply with the section cited above as toxic substances were observed throughout the facility accessible to residents which posed an immediate health risk to persons in care.
8
9
10
11
12
13
14
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 06/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/11/2021
Section Cited

1
2
3
4
5
6
7
87303 Maintenance and Operation. (e)(2)Water supplies and plumbing fixtures shall be maintained as follows: 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…
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA's observations the licensee did not comply with the section cited above as 2 resident bathrooms water temperature tested over 120 degrees F which poses an immediate safety risk to persons in care.
8
9
10
11
12
13
14
Type B
06/18/2021
Section Cited

1
2
3
4
5
6
7
87303 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:
8
9
10
11
12
13
14
Based on LPA's observations the licensee did not comply with the section cited above as the shower room had rust and mildew and room #101 had a hole in the wall which poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 06/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2021
Section Cited

1
2
3
4
5
6
7
87307 Personal Accommodations and Services. Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least…
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA’s observations, the licensee did not comply with the section cited above as all residents beds did not have mattress pads which poses a potential personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
06/18/2021
Section Cited

1
2
3
4
5
6
7
87555 General Food Service Requirements. (b)(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA’s observations, the licensee did not comply with the section cited above as the facility had 5 large cans of fruit which poses a potential personal rights risk to persons in care.
8
9
10
11
12
13
14
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4