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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801810
Report Date: 05/26/2023
Date Signed: 05/26/2023 02:06:24 PM


Document Has Been Signed on 05/26/2023 02:06 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: 257DATE:
05/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Evan Granucci - EDTIME COMPLETED:
01:45 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 05/11/23 and 05/13/23 wherein Residents #1 and #2 fell at the facility and both were hospitalized.

LPA conducted physical plant tour at 10:45 AM, requested copies of facility documents relevant to this visit at 11:30 AM and interviewed staff between 12:00 PM to 1:00 PM.

LPA record review today at 11:30 AM revealed that R1 is independent and currently living alone in own apartment. Further, R1 is ambulatory and able to do everything on R1's own including medication management. R1 was doing R1's regular walk routine when R1 tripped and called the facility staff to assist. Staff called 911 to ensure that R1 was properly evaluated. R1 came back at the facility on the same day.

Further review also revealed that R2 was only provided assistance on bathing, medication management and laundry. R2 was ambulatory and managed everything on R2's own except as mentioned above. R2's most recent fall prior to R1's last fall on 05/13/22 was on 08/20/22. During this time, R2 was immediately assessed by the facility staff and R2's Primary Care Physician (PCP) and was not given any order by the physician nor was declared a fall risk. LPA's interview with staff and ED today between 12:00 PM to 1:00 PM confirmed that R1 did not need any other assistance aside from what was mentioned above.

There is no health and safety issue observed 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: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023
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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