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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561703345
Report Date: 12/15/2022
Date Signed: 12/19/2022 01:26:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2021 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210414134413
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:0CENSUS: 0DATE:
12/15/2022
UNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:N/A Closed facilityTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff did not meet incontinence care needs of resident(s).
Staff did not assist resident(s) with personal hygiene.
Staff did not ensure that resident(s) had clean linens.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales issued final findings for this investigation via certified mail. Facility closed on 6/22/2021.

Concerns were that staff did not meet the incontinence needs of resident #1 (R1) as R1 was observed to be left in soiled diapers for over 2 hours.
On 4/15/21 starting at 12:05 pm interviews were conducted with staff, on 12/8/22 starting at 8:39 am interviews were conducted with staff and resident family members, and on 12/14/22 starting at 1:20 pm interviews were conducted with staff and resident family members. Interviews revealed that residents were observed being left in the dining room in soiled briefs for 5 to 7 hours without being changed. Based on the information obtained during the investigation, the allegation staff did not meet incontinence care needs of resident(s) is substantiated at this time.

Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 29-AS-20210414134413
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/15/2022
NARRATIVE
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Concerns were that staff did not assist residents with personal hygiene as residents were observed wearing dirty clothing and smelling bad.

On 4/15/21 starting at 12:05 pm interviews were conducted with staff, on 12/8/22 starting at 8:39 am interviews were conducted with staff and resident family members, and on 12/14/22 starting at 1:20 pm interviews were conducted with staff and resident family members. Interviews revealed that residents were observed in the dining room smelling bad as they needed to be changed. R2 was observed having dirty hair. Based on the information obtained during the investigation, the allegation staff did not assist resident(s) with personal hygiene is substantiated at this time.

Concerns were that staff did not ensure that resident(s) had clean linens as residents sheets were observed looking dirty with crumbs on them.

On 4/15/21 starting at 12:05 pm interviews were conducted with staff, on 12/8/22 starting at 8:39 am interviews were conducted with staff and resident family members, and on 12/14/22 starting at 1:20 pm interviews were conducted with staff and resident family members. Interviews revealed that when staff would come on shift residents sheets were observed wet or dirty. Based on the information obtained during the investigation, the allegation staff did not ensure that resident(s) had clean linens is substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Today's reports and appeals rights were mailed via certified mail to the former Licensee.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20210414134413
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2022
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence(b)(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
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Facility closed on 6/22/2021
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Based on interviews, the licensee did not comply with the section cited above as residents were observed to be left soiled for an extended period of time which poses an immediate health and personal rights risk to persons in care.
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Type B
12/15/2022
Section Cited
CCR
87464(f)(4)
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87464 Basic Services(f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural...
This requirement is not met as evidenced by:
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Facility closed on 6/22/2021
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Based on interviews, the licensee did not comply with the section cited above as residents were observed smelling and having dirty hair which poses a potential health and personal rights risk to persons 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20210414134413
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2022
Section Cited
CCR
87307(a)(3)(C)
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87307 Personal Accommodations and Services. (a)(3)(C) 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:
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Facility closed on 6/22/2021
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Based on interviews, the licensee did not comply with the section cited above as residents sheets were observed to be wet and dirty which poses a potential health and personal rights risk to persons 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4