561703345-7-21-2021-31-AS-JAPL-C6AT9D-20210827143144

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 561703345
Report Date: 07/14/2021
Date Signed: 07/21/2021 04:34:28 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
03/31/2020 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 31-AS-20200331121102

FACILITY NAME:	TREACY VILLA		FACILITY NUMBER:	561703345
ADMINISTRATOR:	COLLEEN CONBOY		FACILITY TYPE:	740
ADDRESS:	3482 LOMA VISTA RD		TELEPHONE:	(805) 644-1292
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	0	CENSUS: 0	DATE:	07/14/2021
		UNANNOUNCED	TIME BEGAN:	10:22 AM
MET WITH:	Evangeline Ward-Michayluk		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff are not providing resident's authorized representative with resident's medical information
Facility staff are not allowing resident to receive phone calls or visitors
Facility staff convinced resident to change to a physician the facility prefers
Resident's family member did not receive any notification of the COVID-19 visitor policy

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection regarding the above allegations. The facility Treacy Villa closed and had a change of ownership effective June 22, 2021. Today's inspection was conducted at the newly licensed facility Ventura Villa Assisted Living 565802448. The LPA met with current Administrator Evangeline Ward-Michayluk and explained the reason for today's inspection was to interview staff and residents residing at the facility while it was licensed by Treacy Villa.

A virtual inspection was conducted previously on 04/06/2020 of which the LPA conducted an interview with the Administrator Colleen Conboy at 11:50 AM and Witness #1 (W1) at 12:45 PM. On 04/06/2020, the LPA also conducted a telephone interview with Individual #1 (I1) who is the responsible party for Resident #1 (R1).
Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

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 3

Control Number 31-AS-20200331121102

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: 07/14/2021

NARRATIVE

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During the 07/14/2021 inspection the LPA conducted interviews with Staff #1 (S1) and Staff #2 (S2) beginning at 11:17 AM. LPA also conducted interviews with Resident #2 (R2) and Resident #3 (R3) beginning at 2:38 PM. The LPA was informed that R1 no longer resides at this location and there are no records for R1 at this location.

The allegation of "Facility staff are not providing resident's authorized representative with resident's medical information" alleges the family member of R1 would like to speak to R1's physician about a new medication R1 is receiving but the Administrator gave R1's family member the wrong phone number for R1's physician. Interviews with the Administrator revealed the family member of R1 stated W1, who is not an employee of the facility, gave them the wrong number for the physician. The Administrator also stated R1 has not had any recent medication changes. During the interview with W1, W1 denied giving the family member the wrong phone number. During the interview with Individual #1 (I1) they stated they had no issues or concerns with obtaining physician information or medications or medication changes. Based on the information obtained, the allegation of "Facility staff are not providing resident's authorized representative with resident's medical information" is deemed unsubstantiated at this time.

The allegation of "Facility staff are not allowing resident to receive phone calls or visitors" alleged the family member of R1 was not allowed to call or visit R1. During the interview with the Administrator, visitors are currently meeting with residents for outside visitation. The administrator stated she was not aware the family member of R1 had made any attempts to visit R1 or wanted to visit R1. The Administrator stated there have been issues with the family member yelling at staff on the telephone and staff ending the call due to this but the family member has never been denied the ability to speak with R1. Interviews with R2 and R3 revealed no issued or concerns with visitation or telephone access. Based on the information obtained, the allegation of "Facility staff are not allowing resident to receive phone calls or visitors" is deemed unsubstantiated at this time.

Report continued on LIC 9099-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200331121102

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: 07/14/2021

NARRATIVE

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The allegation of "Resident's family member did not receive any notification of the COVID-19 visitor policy" alleges R1's family member did not received any notification of the COVID-19 visitor policy. During the interview with the Administrator, they stated either mailed or emailed Individual #1 (I1), who is the responsible party for R1, the visitor policy. During the interview with I1, I1 stated they could not recall if the facility gave them a copy of the visitor policy but stated they were aware of the policy and obtained a copy of the visitor policy when they visited the facility. I1 stated they also gave R1's family member of copy of the policy. Based on the information obtained, the allegation of Resident's family member did not receive any notification of the COVID-19 visitor policy is deemed unsubstantiated at this time.

The allegation of " Facility staff convinced resident to change to a physician the facility" prefers alleges the facility convinced the resident to change physician's to a doctor who conducts visits at the facility. The administrator stated the resident changed physician's two or three weeks ago due to the family having a hard time getting the resident to appointments. The Administrator said the family member of R1 and I1 agreed to changing to a physician who conducts visits at the facility. During the interview with I1, I1 stated they and the family member agreed to the physician change. Based on the information obtained, the allegation of Facility staff convinced resident to change to a physician the facility is deemed unsubstantiated at this time.

On July 15, 2021 at 5:08 PM, LPA Lopez spoke with former licensee Mr. Patrick Treacy on the telephone and explained the complaint findings. LPA Lopez obtained a current mailing address for the licensee and advised a copy of the report and appeal rights would be mailed to the him for signature.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021

LIC9099 (FAS) - (06/04)

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