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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800683
Report Date: 03/24/2021
Date Signed: 03/25/2021 04:34:46 PM

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:AEGIS OF VENTURAFACILITY NUMBER:
565800683
ADMINISTRATOR:BASSEM EL-RABAAFACILITY TYPE:
740
ADDRESS:4964 TELEGRAPH ROADTELEPHONE:
(805) 650-1114
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:100CENSUS: 69DATE:
03/24/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:Sam El-RabaaTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a case management investigation telephonically with Administrator Sam El-Rabba due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures.

On 3/23/21 LPA spoke with Administrator regarding an incident report received for resident #1 (R1) indicating that R1 eloped from the facility on 3/20/21. Administrator stated that on 3/20/21 staff #1 (S1) saw R1 in the lobby at approximately 6:10 pm and when S1 went to R1’s room at approximately 6:45 pm to give R1 their medications they were not in their room. Administrator stated that S1 searched for R1 throughout the facility and they were unable to locate the R1. Administrator stated that they contacted the police and R1’s family. Administrator stated that R1 was found at Camino Real Park (1.1 miles away) by a private citizen who contacted the facility at approximately 8:10 pm. Administrator stated that R1 was picked up by facility staff and returned to the facility. Administrator stated that R1 did not sustain any injuries. Administrator stated that a wander guard was placed on R1's wrist with family approval. Administrator stated that R1 must have left the facility through the front door after 6:30 pm as that is when the concierge leaves. Administrator stated that they have changed the concierge hours to be present at the desk until 8 pm. Administrator stated that the front door is alarmed after 7 pm. Administrator stated that they are conducting staff training regarding elopement policies and protocols.

R1’s records reviewed on 3/24/21 at 8:30 am revealed that R1 is not able to leave the facility unassisted. On 3/20/21 staff failed to supervise R1 as R1 eloped from the facility.

During today’s visit LPA toured the facility with the Administrator. Administrator stated that S1 observed R1 in their room at approximately 6:10 pm and not in the lobby as previously stated by the Administrator on 3/23/21.

Continued on 809-C

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

DATE: 03/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: AEGIS OF VENTURA
FACILITY NUMBER: 565800683
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2021
Section Cited

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87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
This requirement is not met as evidenced by:
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Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which poses an immediate health and safety 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: 03/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AEGIS OF VENTURA
FACILITY NUMBER: 565800683
VISIT DATE: 03/24/2021
NARRATIVE
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Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

A telephonic exit interview was conducted with the Administrator, and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021
LIC809 (FAS) - (06/04)
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