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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800683
Report Date: 07/02/2021
Date Signed: 07/02/2021 05:28:59 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:
07/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Sam El-RabaaTIME COMPLETED:
03:30 PM
NARRATIVE
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This Case management visit was conducted to address the deficiencies noted during the Pre-Licensing and complaint control #29-AS-20210625141736 investigation visit conducted on 7/2/21.

During facility tour with Administrator at 11:23 am LPA observed a water fountain in the courtyard with water accessible to residents.

During facility tour with Administrator at 11:30 am LPA observed furniture polish, stainless steel cleaner and polish, disinfectant spray, concentrated laundry destainer and laundry detergent in laundry room accessible to residents.

During facility tour with Administrator at 12:03 pm LPA observed jock itch cream in resident #1 (R1) bathroom accessible to residents. R1's bedroom door was observed unlocked by LPA and Administrator.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Civil penalties assessed in the amount of $750.00

Exit interview conducted, today's reports, civil penalties and appeal rights were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
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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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: 07/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2021
Section Cited

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87307 Personal Accommodations and Services.(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water...through fencing, covering or other means.
This requirement is not met as evidenced by:
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Based on LPA's observation, the licensee did not comply with the section cited above as the facility had a water fountain in the backyard with water accessible to residents which poses an immediate health and safety risk to persons in care.
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Type A
07/03/2021
Section Cited

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as jock itch cream and toxic substances were observed in the R1's bathroom and laundry room accessible to residents which posed an immediate health 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: 07/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2021
LIC809 (FAS) - (06/04)
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