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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561703345
Report Date: 12/04/2022
Date Signed: 12/04/2022 11:43:52 AM

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
09/08/2020 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20200908144505
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:
12/04/2022
UNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:N/A Closed FacilityTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff not meeting residents needs
Staff not using proper sanitizing methods
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon issued final findings for this investigation via certified mail, regular mail and email. The facility closed on 6/22/2021.

During the investigation, LPA Rosales conducted staff interviews on 9/10/2020 at 2:22pm, 2:52pm, 3:20pm, 3:41pm, 4:27pm, and 4:38pm.

On the allegation: Staff not meeting residents needs. It was alleged that staff were not changing residents into their pajamas and let them sleep in their clothes, were not giving them showers, and were not assisting with toileting. Multiple staff interviewed stated that former caregivers, who were no longer working at the facility, were not changing the clothes of some of the residents and they observed residents in the same clothing from the day before. Staff stated that was not happening anymore as of the interview date.
Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2022
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 5
Control Number 29-AS-20200908144505
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: 12/04/2022
NARRATIVE
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 All staff interviewed stated sometimes residents refuse showers, but residents get at least two showers per week. Multiple staff confirmed hospice assisted with showers for residents on hospice. All staff interviewed indicated resident toileting needs were met. Based on the interviews of multiple staff stating some staff were not assisting residents with dressing, the allegation is deemed Substantiated at this time.

On the allegation: Staff not using proper sanitizing methods. It was alleged that staff wear one pair of gloves all day and do not change them between residents. Multiple staff interviewed stated they have “boxes and boxes” of gloves and change gloves after each resident. One staff stated months before the date of the interview, former staff were not changing their gloves and were walking around the facility with them on. This staff stated at the time they were limited on gloves, during the COVID-19 pandemic, but have enough gloves now. Based on the information obtained, the allegation is deemed Substantiated at this time. Infection Control Regulations became effective after the date of this complaint, therefore Technical Assistance is provided in lieu of a formal citation.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, deficiencies were cited (refer to LIC 9099-D).

Reports and appeal rights were Certified mailed/mailed/emailed to the former Licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20200908144505
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: 12/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2022
Section Cited
CCR
87464(f)(4)
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...Personal assistance and care as needed by the resident...,with those activities of daily living such as dressing,eating,bathing prescribed medications…This requirement is not met as evidenced by:
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Facility Closed.
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Based on interview, the licensee did not comply with the above cited section when staff did not assistance residents with dressing, which posed a potential health and safety risk to residents 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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 Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20200908144505

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:
12/04/2022
UNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:N/A Closed FacilityTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Staff did not provide basic laundry services.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) De Leon issued final findings for this investigation via certified mail, regular mail and email. The facility closed on 6/22/2021.

During the investigation, LPA Rosales conducted staff interviews on 9/10/2020 at 2:22pm, 2:52pm, 3:20pm, 3:41pm, 4:27pm, and 4:38pm.

On the allegation: Staff did not provide basic laundry services. It was alleged that the laundry was not being done and there were piles of dirty laundry in residents’ rooms. Staff interviewed stated one staff was doing the laundry and it was being done “non-stop.” Staff interviewed stated resident laundry was not piled up in the resident’s room as it was done “all night and all day.”
Continued 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20200908144505
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: 12/04/2022
NARRATIVE
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 The staff responsible for laundry stated they do laundry “everyday all day.” The staff responsible for laundry stated a former manager told them to leave dirty clothes in the laundry baskets in resident rooms, but the staff did not like to do that because the laundry would smell. The staff responsible for laundry stated that they were no longer leaving dirty laundry in resident room. Staff stated laundry is finished by 3pm. Staff stated they have 2 dryers and 3 washing machines. Staff stated that 1 of the dryers was broken for 2 to 3 days once at the same time the maintenance person was out sick. Other staff stated 1 washer and 1 dryer were broken for around 5 to 7 days. Staff stated the delay in laundry was not due to staffing but was due to the machines not working. Although laundry may have been delayed for a period between 2 and 7 days when a machine was broken, the facility fixed the machine, and still had functioning machines during the time period. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview, report emailed, Certified mailed and mailed to former Licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5