565801810-10-21-2021-31-AS-JROS-C823R6-20211021182811

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801810
Report Date: 10/21/2021
Date Signed: 10/21/2021 06:29:01 PM

Document Has Been Signed on 10/21/2021 06:29 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VENTURA TOWNEHOUSE		FACILITY NUMBER:	565801810
ADMINISTRATOR:	EVAN GRANUCCI		FACILITY TYPE:	740
ADDRESS:	4900 TELEGRAPH ROAD		TELEPHONE:	(805) 642-3263
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	566	CENSUS: 215	DATE:	10/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Evan Granucci		TIME COMPLETED:	04:50 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) JoAnn Rosales conducted an unannounced Required - 1 year inspection. LPA met with Administrator Evan Granucci. A physical plant tour was conducted to ensure there are no health and safety hazards. The facility is currently fire cleared for 566 non-ambulatory residents of which 6 may be bedridden. The facility was observed to be clean, safe, sanitary, and in good repair. LPA observed one central entry point designated for universal entry screening. Cleaning supplies were observed and infection control practices were discussed. An inspection of the common area, random resident rooms and restrooms were conducted. LPA observed COVID signs and sanitizing stations throughout the facility. Hot water was tested at 116.4, 115.2, and 113.4 degrees F in resident bathrooms. The resident restrooms were observed to be clean and sanitary and in working condition. There is an adequate amount of perishable and non-perishable food. LPA observed fire extinguishers fully charged. Carbon monoxide detectors were tested and operable. Fire alarms are hard wired and serviced by MJM Communications. They have a 24 hr a day monitoring system. Administrator provided proof of annual testing conducted on 11/6/2020. Grab bars were present in the bathrooms. Hygiene items are being provided. LPA observed working signal system. LPA observed appropriate lighting in the facility. LPA observed residents and staff wearing face masks. Outdoor area toured- passageways are free of obstruction. LPA reviewed random resident records. During facility tour starting at 12:18 pm with Administrator LPA observed resident #1 (R1) and R2's bedroom door unlocked and NovoLog flexpen insulin aspart injection prefilled syringe, lantus insulin glargine injection prefilled pen, entresto tabs, allopurinol tabs, atorvastatin tabs, cholecalcif tablets, levothyroxine tablets, furosemide tabs, linaclotide capsules, glipizide tabs, valsartan tabs, clopidogrel bisulfate tabs, loratadine tabs, glucosamine chondroitin capsules, benzonatate capsules, aspirin, metformin tabs, carvedilol tabs in Continued on 809-C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VENTURA TOWNEHOUSE	FACILITY NUMBER: 565801810
	VISIT DATE: 10/21/2021

NARRATIVE

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R1 and R2's bedroom accessible to residents.

During a review of resident records at 3:30 pm LPA observed that R3 does not have a TB test on file.

Due to time constraints, the LPA will return at a later date to continue the inspection.

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

Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to the Administrator.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/21/2021 06:29 PM - It Cannot Be Edited

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VENTURA TOWNEHOUSE	FACILITY NUMBER: 565801810
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations the licensee did not comply with the section cited above in 2 out of 10 resident medications which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/21/2021
	Plan of Correction
1 2 3 4	Administrator locked R1 and R2's bedroom door during facility visit. Administrator stated that they will speak with R1 and R2 about keeping their bedroom door locked.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/21/2021 06:29 PM - It Cannot Be Edited

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VENTURA TOWNEHOUSE	FACILITY NUMBER: 565801810
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 10 resident records which poses a potential health risk to persons in care.
	POC Due Date: 10/28/2021
	Plan of Correction
1 2 3 4	Administrator stated that they will provide documentation of R3's TB test to CCL by 10/28/21.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

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