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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561703345
Report Date: 05/19/2021
Date Signed: 05/19/2021 03:55:07 PM



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
09/09/2020 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20200909150028
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: 22DATE:
05/19/2021
UNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Evangeline (Joy) MichaylukTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Facility staff mismanage residents' medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint inspection at the facility today. The LPA arrived at 1:57 PM and met with Administrator Evangeline (Joy) Michayluk. The LPA informed the Administrator of the reason for today's inspection.

Previously, during an onsite outdoor initial complaint investigation on 9/10/2020, LPAs Kelly Dulek and JoAnn Rosales conducted staff interviews from 2:19PM - 5:02PM and LPAs obtained copies of pertinent documents. During today's visit, LPA Dulek conducted a medication audit at 3:16PM. Interviews revealed residents regularly receive their medications. Although the Medication Technicians assist with some caregiving duties as needed, medications are administered regularly on time for all residents. None of the staff interviewed were aware of any reports of residents missing medication doses or any medication errors occuring. During the medication review, LPA Dulek reviewed medications for 2 residents, including Resident #1 (R1). All medications observed are administered per physician's orders and recorded per Title 22 regulation.
Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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 2
Control Number 29-AS-20200909150028
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: 05/19/2021
NARRATIVE
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The following was then determined: based on interviews and medication review, there is insufficient evidence to support the above allegation, therefore the allegation that "facility staff mismanage residents' medications" is deemed UNSUBSTANTIATED at this time.

Exit interview was conducted with Administrator and a copy of the report was provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
LIC9099 (FAS) - (06/04)
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