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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801810
Report Date: 05/15/2023
Date Signed: 05/15/2023 02:20:37 PM


Document Has Been Signed on 05/15/2023 02:20 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



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: 258DATE:
05/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Evan Granucci - Executive DirectorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced case management visit at this facility to follow up on the incident occurred on 04/25/23 wherein Resident #1 (R1) was reported to have died of blunt force trauma. LPA conducted physical plant tour at around 9:45 AM, requested copy of facility documents relevant to the investigation at 10:35 AM and interviewed staff between 11:00 AM to 12:30 PM. LPA also reviewed records between 12:30 PM to 1:30 PM.

LPA record review today between 12:30 to a:30 PM revealed that R1 had an unwitnessed fall on 04/09/23 at approximately 4:00 PM at own apartment. R1 was able to call family member who called 911 who picked R1 at the facility to bring to the hospital. Further record review revealed that R1 was ambulatory and did not need any assistance on Activities of Daily Living (ADLs) including showering, transferring, toileting, grooming, etc. LPA's interview with the Executive Director and staff today revealed that R1 returned to the facility on 04/19/23 with Hospice Care services and passed away on 04/25/23 while in the care of a Hospice agency.

There is no immediate health and safety concern during this visit.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023
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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