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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561703345
Report Date: 07/17/2023
Date Signed: 07/17/2023 02:56:03 PM

Unsubstantiated


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
05/18/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210518164037
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:
07/17/2023
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Erendira GuadarramaTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff inappropriately touched resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to deliver findings for the above allegation. This facility went through a Change of Ownership (CHOW) and closed on 6/22/2021; hence, the LPA delivered findings at Ventura Villa Assisted Living (565850093). The LPA met with staff Erendira Guadarrama and explained the reason for the visit.

On 05/18/2021, a complaint was submitted, alleging that Staff #1 (S1) inappropriately touched Resident #1 (R1). On 05/19/2021, LPA Kelly Dulek conducted an initial visit, where they interviewed R1 and the Administrator from 2:00 p.m. - 2:53 p.m., conducted a tour with the administrator at 2:56PM, and gathered documents. On 06/20/2023, LPA Smith conducted a subsequent visit, in which they toured the facility, and interviewed five (5) staff, and three (3) residents from 9:45 a.m. – 1:30 p.m. A collateral visit took place at Cypress Place Assisted Living (567609978), to interview S1, and an additional staff member at 1:55 p.m. and 2:07 p.m. Interviews of former staff were conducted on 06/20/2023 at 4:12 p.m., on 06/22/2023 at 1:17 p.m. and 1:47 p.m., and 06/26/2023 at 5:25 p.m.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
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 3
Control Number 29-AS-20210518164037
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: 07/17/2023
NARRATIVE
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Regarding the allegation, it was alleged that S1 was being ‘inappropriate with one or two of the residents.’ Whereas additional interviews took place around the time the complaint was submitted, no additional information was obtained from residents, other than a complaint from R1. R1 alleged that S1 would change their pull-up, in which they would ‘touch their privates’ and R1 did not like it. R1 described that S1 would use a washcloth or wet wipe to clean R1, and denied claims that S1 would ever use their bare hands to touch them. R1 stated at the time of the complaint that they did not like it, and that they would tell S1 to stop. During the interview conducted with R1 on 05/19/2021, R1 claimed that they did not describe what S1 was doing to them as ‘taking care of them’ when they were cleaning them up. R1 alleged that S1 would ‘make fun’ of them when changing their briefs and said that a total of three (3) staff would come into the room when the alleged act took place. Records review indicated that R1 had a diagnosis of dementia and required assistance with activities of daily living.

The Administrator confirmed on 05/19/2021 during the interview that S1 had been fired for the allegation of being inappropriate with a resident. The Administrator did not have direct knowledge of the act, but claimed it was mentioned by staff. Records and interviews indicated that S1 primarily worked the overnight/NOC shift. The Administrator noted during the interview that S1 refuted claims that they had been inappropriate with a resident. Yet, various statements were obtained from interviews conducted with staff who worked alongside S1. Whereas R1 claimed that three (3) staff would come into their room to change their brief, staff who worked NOC shift stated that they had separate assignments and oftentimes did not work together when completing resident care.

Most current and former staff interviewed commented no concerns in working with S1 and denied claims that S1 had been inappropriate with residents in care. Staff were unable to corroborate claims that S1 was inappropriate with R1 but one staff that worked alongside S1 during NOC shift noted that S1 appeared to handle R1 roughly when changing them. Staff admitted that S1 was rumored to have slept during the NOC shift in the chair of another resident’s room. A review of S1’s files supported this claim, as S1 had been written up for sleeping during NOC shift. Information obtained from resident interviews was insufficient to support claims of any inappropriate touch, as residents communicated no concerns with resident care, and appeared happy to be residing at the facility.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210518164037
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: 07/17/2023
NARRATIVE
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During an interview with S1, S1 confirmed that they were fired for an allegation of touching R1 inappropriately but denied claims of ever being inappropriate with R1 or any resident that resided at Treacy Villa. S1 also refused claims that they had ever mocked a resident or made fun of them. S1 said that they had been at Treacy Villa for approximately 20 years before they were fired and said they had written complaints about other staff members but said those weren’t ever considered. Interviews with staff that currently work with S1 denied claims of observing S1 being inappropriate with any residents, and noted that S1 had positive relationships with staff and residents at the facility they currently worked in.

Based on the information obtained in interviews and records review, there is insufficient evidence to support the claim that S1 inappropriately touched R1. When the allegation was brought to the attention of the Administrator, the Administrator fired S1. However, although the allegation may have happened or is valid, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3