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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801810
Report Date: 08/31/2022
Date Signed: 08/31/2022 12:48:35 PM

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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/24/2022 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220524161324
FACILITY NAME:VENTURA TOWNEHOUSEFACILITY NUMBER:
565801810
ADMINISTRATOR:EVAN GRANUCCIFACILITY TYPE:
740
ADDRESS:4900 TELEGRAPH ROADTELEPHONE:
(805) 642-3263
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:566CENSUS: 242DATE:
08/31/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Evan GranucciTIME COMPLETED:
12:47 PM
ALLEGATION(S):
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Resident had a fall due to lack of supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a subsequent unannounced complaint visit to complete an investigation for the above noted allegation and to deliver final findings. LPA met with Administrator Evan Granucci.

Concerns were that resident #1 (R1) had a fall due to lack of supervision and sustained facial lacerations and a skin tear. During this investigation on 05/26/22 at 11:07am LPA Rosales inspected R1’s room and spoke with R1. Staff interviews conducted on 5/26/22 starting at 10:27 am and 8/26/22 starting at 4:23 pm revealed that on 5/23/22 staff #1 (S1) was in the R1’s room to assist with dressing and was standing a couple of steps away facing R1, who was sitting on the bed and chose to put on their pant leg on themselves. While R1 was still trying to put their pant leg on, S1 turned around to look out the window and when S1 turned back, they observed R1 on the floor. Staff stated that R1 fell on their right elbow and hit their right side of their eyebrow on the floor.
Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
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 3
Control Number 31-AS-20220524161324
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VENTURA TOWNEHOUSE
FACILITY NUMBER: 565801810
VISIT DATE: 08/31/2022
NARRATIVE
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Staff called 911 and R1 sent out to the hospital.

A review of R1’s facility records conducted on 05/26/22 at 11:43am revealed that R1 required assistance with dressing and grooming.

Based on interviews, inspection, observation and record review, it was concluded that although staff was present in the room, at the time of R1’s fall S1 was not facing R1 to provide hands on assistance to prevent the fall. Therefore, the allegation is deemed SUBSTANTIATED at this time.

Exit interview was conducted. Today's reports and appeals rights were reviewed and copy of report was issued.



Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220524161324
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VENTURA TOWNEHOUSE
FACILITY NUMBER: 565801810
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2022
Section Cited
CCR
87464(d)
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87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal….
This requirement is not met as evidenced by:
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Administrator stated that they will provide documentation of scheduled staff inservice regarding regulation 87464(d) to CCL by 9/1/22. Administrator stated that they will provide documentation of staff training to CCL by 9/12/22.
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Based on LPA’s observation, interview and record review, the licensee did not comply with the section cited above as R1 had a fall due to lack of supervision which posed 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3