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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800253
Report Date: 05/15/2024
Date Signed: 05/15/2024 02:27:50 PM

Document Has Been Signed on 05/15/2024 02:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ASSOCIATION FOR RETARDED CITIZENS - VENTURAFACILITY NUMBER:
565800253
ADMINISTRATOR/
DIRECTOR:		MITCHEL GARCIAFACILITY TYPE:
775
ADDRESS:3340 E. LOS ANGELES AVENUETELEPHONE:
(805) 527-1358
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 90CENSUS: 28DATE:
05/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Mitchel GarciaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management visit to continue the investigation of the initial case management- Incident visit conducted on 05/02/2024.

On 05/02/2022 between 12:55pm - 3pm,  LPA's Brian Balisi and Martha Arroyo conducted physical plant, interviewed staff and reviewed and obtained copies of pertinent documents relevant to the incident. On 05/15/2024, LPA Balisi conducted physical plant, interviewed staff and reviewed records.
It was reported that on 04/20/2024, Staff #2 (S2) stood alongside Participant #2 (P2) and  poured a small amount of non-toxic blue paint into a red plastic cup. According to S2 the amount  they poured was less than a tablespoon. S2 continued to state as soon as they finished pouring the paint into the cup, they were asked a question by another staff member in the room and S2 walked over a few a feet  and turned their attention to the staff to respond to their question. Another participant who was in the room got the attention of S2 to inform them P2 grabbed the plastic cup and drank from it. Staff immediately brought P2 to a nearby sink and to clean the sides of their mouth and drink water. P2 did not express any concerns to staff and did not appear to be in any pain or discomfort that day. LPA's records review revealed P2 requires 1:1 at all times during program hours. Individual Service Plan (ISP) dated 04/29/2024, also indicated that "P2 tries to eat non-food items and needs to be monitored consistently".

It was reported that on 04/02/2024, Participant #1(P1) did not have a beverage while attending program for approx (8) hours. Interviews conducted revealed that Staff #1 (S1) , was aware that S1 brought a juice beverage to program that day,but there was an oversight in providing P1 with their juice.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.
Exit interview conducted. A copy of the report and appeal rights provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2024 02:27 PM - It Cannot Be Edited


Created By: Brian Balisi On 05/15/2024 at 02:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASSOCIATION FOR RETARDED CITIZENS - VENTURA
FACILITY NUMBER: 565800253

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
82078(a)

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82078(a) The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement.
This requirement was not met as evidence by:
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Licensee agreed to review regulation cited and provide LPA with a letter of understanding by 05/31/2024 via email EOD.
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Based on records review and interviews conducted, the licensee did not comply with the section cited above as P1 and P2 were not provided the necessary care and supervision which is potential health and safety risk to participants 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:Desaree Perera
LICENSING EVALUATOR NAME:Brian Balisi
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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