561703345-9-27-2022-29-AS-KHEN-CKJUMN-20221025154235

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 561703345
Report Date: 09/14/2022
Date Signed: 09/27/2022 01:15:16 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
09/08/2020 and conducted by Evaluator Joann Rosales

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20200908161016

FACILITY NAME:	TREACY VILLA		FACILITY NUMBER:	561703345
ADMINISTRATOR:	EVANGELINE MICHAYLUK		FACILITY TYPE:	740
ADDRESS:	3482 LOMA VISTA RD		TELEPHONE:	(805) 644-1292
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	0	CENSUS: 0	DATE:	09/14/2022
		UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Patrick Treacy		TIME COMPLETED:	10:58 AM

ALLEGATION(S):

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Neglect/Lack of Supervision: Facility Resident #1 (R1) sustained an unexplained hairline fracture while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) JoAnn Rosales conducted a telephone visit with Licensee Patrick Treacy to deliver investigation findings as the facility was closed effective 6/22/21.

On 09/08/2020, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that facility Resident #1 (R1) sustained an unexplained hairline fracture while in care. The complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Laura Garcia.

On 09/10/2020, from 2:05 pm to 5:25 pm, Licensing Program Analysts (LPAs) JoAnn Rosales and Kelly Dulek conducted an initial 10-day complaint visit and met with Administrator Evangeline Michayluk. During the visit, LPA Rosales interviewed a random sample of staff outside of the facility due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. LPA also obtained copies of Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200908161016

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: 09/14/2022

NARRATIVE

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pertinent documents. The LPA determined further investigation was required.

On 9/25/2020 at approximately 11:00 am, Investigator Garcia conducted an interview with the Reporting Party, Administrator on 10/2/2020 at approximately 9:00 am, former staff on 10/27/2020 at approximately 10:30 am, staff on 12/14/2020 at approximately 2:00 pm and residents’ responsible persons on 12/22/2020 at approximately 10:10 am to 4:00 pm.

Investigator Garcia also reviewed R1’s medical and hospice records. The records revealed that R1 was taken to the Emergency room on 9/6/2020 and admitted to the hospital on 9/7/2020 due to an altered mental state and difficulty speaking. Among several chronic illnesses and hospice care noted, there was also pain noted to R1’s left arm. R1 reported left, upper extremity pain over the proximal end of R1’s humerus which was ultimately negative for fractures via x-ray. Both left shoulder and left elbow were x-rayed as well and showed no evidence of any acute fractures or abnormalities. Additionally, a CT scan of the cervical spine was performed, and there was no contrast or acute fracture. R1 was discharged on 9/9/2020 to their home in stable condition.

Although the reporting party alleged that R1 sustained an unexplained hairline fracture while in care, medical records do not support the allegation. Based on the information obtained, there is insufficient evidence to support the allegation. Therefore, the allegation Resident #1 (R1) sustained an unexplained hairline fracture while in care is deemed Unsubstantiated at this time.

Exit interview conducted. Today's reports and appeals rights were reviewed and mailed certified mail to the Licensee.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC9099 (FAS) - (06/04)

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