565801074-3-5-2025-29-AS-TCAA-DEH23Y-20250305160303

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801074
Report Date: 03/05/2025
Date Signed: 03/05/2025 04:03:35 PM

Document Has Been Signed on 03/05/2025 04:03 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CRESTWOOD VILLA II		FACILITY NUMBER:	565801074
ADMINISTRATOR/ DIRECTOR:	RAIMONDA BANAKIENE		FACILITY TYPE:	740
ADDRESS:	452 HEIDELBERG AVENUE		TELEPHONE:	(805) 639-0439
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	03/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:20 AM
MET WITH:	Raimonda Banakiene		TIME VISIT/ INSPECTION COMPLETED:	02:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit. LPA met with administrator Raimonda Banakiene and explained the reason for the visit. LPA conducted a tour of the physical plant with the Administrator. The following was noted: Facility is a single-story residence that consists of six (6) resident bedrooms and two (2) bathrooms. The LPA observed (1) fully charged fire extinguisher that was purchased on 3/4/2024. All smoke alarms and carbon monoxide detectors were tested at 11:52 a.m. and functioned properly. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Knives are stored in the locked medication closet near the front entry. Bedrooms: The resident bedrooms were properly furnished with a chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: LPA observed all bathrooms clean, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. Hot water temperature was 115 degrees Fahrenheit. (Continued on LIC809-C)

Desaree Perera	TELEPHONE: (818) 593-4347
Teresa Camara	TELEPHONE: 818-326-4019
	DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CRESTWOOD VILLA II	FACILITY NUMBER: 565801074
	VISIT DATE: 03/05/2025

NARRATIVE

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(continued from LIC809)

Common Areas: These included a living room, family room, and dining area. These areas were properly furnished and functional for residents. The facility maintained a comfortable temperature. There is a hall closet which contained linens and hygiene supplies.

Garage: The locked garage had a washer and dryer, cleaning supplies, PPE, and some additional food.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

Medications: LPA reviewed the centrally stored medication and destruction records (CSMDR). LPA reviewed medications which were properly documented on the CSMDR and appear to be given as prescribed.

Interviews: LPA spoke with two residents who were happy with the facility staff, cleanliness, care, and food. They had no concerns. LPA spoke with staff as well; there were no concerns.

File review: LPA reviewed all six (6) residents' files; all files were complete. LPA reviewed five (5) staff files and the administrator's file. All staff are fingerprint cleared and associated to the facility. All staff have their health screenings, training and other personnel records.

Infection Control and Emergency Disaster Plan: LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills will be conducted quarterly with all staff. Emergency disaster plan was observed to be complete.

No deficiencies observed. Exit interview conducted and copy of the report provided to Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025

LIC809 (FAS) - (06/04)

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