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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561703345
Report Date: 06/23/2021
Date Signed: 06/23/2021 04:08:59 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
06/18/2021 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210618105731
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:
06/23/2021
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Evangeline MichaylukTIME COMPLETED:
03:38 PM
ALLEGATION(S):
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Facility did not inform responsible party regarding change in resident's medical care
INVESTIGATION FINDINGS:
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During today's visit Licensing Program Analyst (LPA) JoAnn Rosales toured the facility with staff Jennifer Sharma, reviewed random resident records, interviewed random staff and resident and obtained copies of pertinent documents.

Concerns were that the facility did not inform resident #1 (R1)'s responsible party regarding a change in residents pharmacy provider around September 2020 prior to the change. Interview with staff #1 (S1) starting at 11:38 am revealed that the Administrator changed residents pharmacy providers around September or October 2020. S1 was not aware of residents responsible parties being notified of the changes. Interview with Administrator starting at 1:23 pm revealed that they changed residents pharmacy providers around September or October 2020 and did not notify residents responsible parties until after they made the changes. Based on the information obtained during the course of the investigation this allegation is deemed substantiated at this time.
Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to Administrator.
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: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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 4
Control Number 29-AS-20210618105731
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: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2021
Section Cited
HSC
1569.269(a)(20)
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1569.269 Enumerated rights; severability.(a)(20) To select their own physicians, pharmacies, privately paid personal assistants, hospice agency... in a manner that is consistent with the resident’s contract of admission or other rules of the facility, and in accordance with this act.
This requirement is not met as evidenced by:
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Administrator stated that they will review and comply with section 1569.269 Enumerated rights and will provide a letter to CCL by 6/30/21 indicating this.
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Based on interviews, the licensee did not comply with the section cited above as the Administrator changed residents pharmacy providers without prior notification to responsible parties which posed a potential 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: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
06/18/2021 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210618105731

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:
06/23/2021
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Evangeline MichaylukTIME COMPLETED:
03:38 PM
ALLEGATION(S):
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Facility did not arrange transportation for resident's medical care
Facility did not allow resident to have a visitor
Facility did not follow resident's physician's order regarding care
INVESTIGATION FINDINGS:
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During today's visit Licensing Program Analyst (LPA) JoAnn Rosales toured the facility with staff Jennifer Sharma, reviewed random resident records, interviewed random staff and resident and obtained copies of pertinent documents.

Concerns were that the facility did not arrange transportation for R1 to go to the emergency room after a 911 call on 5/31/21. A review of R1's records starting at 11:11 am revealed that R1 was taken to the hospital on 5/31/21 by Emergency Medical Services. A review of R1's Admission Agreement reveals that if the facility makes the appointment they can take the resident to the appointment. Interview with S2 starting at 12:28 pm revealed that on 5/31/21 911 was called for R1. S2 stated that for medical emergencies 911 is called and they will take residents to the hospital if they need to go. Interview with S3 starting at 12:44 pm revealed that on 5/31/21 they called 911 for R1 and then called R1's responsible party. S3 stated that they told the paramedics that the facility does not provide transportation. Interview with Administrator starting at 1:23 pm
Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20210618105731
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: 06/23/2021
NARRATIVE
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revealed that on 5/31/21 S3 called 911 for R1. Administrator stated that they do not take residents to the hospital on a 911 call as they are not equipped to do that. Concerns were that the facility did not allow R1 to have a visitor on 6/17/21. Interview with S4 starting at 12:03 pm revealed that R1's responsible party went to the facility to visit R1 without an appointment. S4 stated that they asked R1's responsible party to wait in the patio and they would take R1 to the patio to visit their responsible party until 5 pm. Interview with S3 revealed that R1's responsible party did not have an appointment to visit R1 on 6/17/21 so they advised R1's responsible party to sit in the courtyard and wait for R1. S3 stated that they called S4 who went to speak with R1's responsible party. S3 stated that S4 told R1's responsible party that they could visit R1 until 5 pm. Interview with Administrator revealed that they have not denied any residents visitors. Concerns were that the facility did not follow R1's physician's order to have the resident walk for at least 300 feet using a walker 3 times a day. LPA did not observe a physician order for R1 to walk for at least 300 feet using a walker 3 times a day while reviewing R1's records starting at 11:11 am. Interview with S1, S2 and the Administrator revealed that R1 does not have a physician order to have the resident walk for at least 300 feet using a walker 3 times a day.

Based on the information obtained during the course of the investigation the allegations are deemed unsubstantiated at this time.

Exit interview conducted. Today's reports and appeals rights were reviewed and emailed to Administrator.

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

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4