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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801810
Report Date: 11/21/2023
Date Signed: 11/21/2023 11:01:17 AM


Document Has Been Signed on 11/21/2023 11:01 AM - 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: 250DATE:
11/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Evan GranucciTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a (24) hour case management visit, pertaining to a Special Incident Report (SIR) notification of a resident's death.

On 11/20/2023, Administrator Evan Granucci contacted Licensing and spoke to LPA Angela P. who reported: "At 3:26pm, LPA (OD) received a phone call from the Administrator, Evan Granucci, and was informed that on 11/20/23 around 11:30am, resident # 1 (R1) went up to the 7th floor, which is a common area with an outdoor veranda, moved a chair close to the fence, R1 got over the fence and jumped. The body was discovered by another resident, who later reported to the concierge. LPA was informed that the resident was receiving Hospice Services and lived in an Assisted Living (independent) area. Due to the nature of the death 911 was called and police report filed. LPA was informed that the Death and Police report will be submitted promptly".

During today's visit, LPA interviewed the Administrator and obtained R1's facility records. According to the Administrator, a hour prior to the incident, R1 was seen by staff, and there were no signs of distress. R1 does not have a history of depression, or suicidal ideation; but was recently admitted to hospice 10/11/2023, for coronary artery disease . Staff found R1 outside on the ground unresponsive with no pulse. 911 was called and R1 was pronounced deceased. The Ventura County police department were contacted; who visited the facility, the same day of the incident and reviewed facility surveillance. It was observed R1 used a facility chair and climbed over the railing from the 7th floor. The police deemed the incident as a suicide and no foul play. It was also reported that there were no witnesses by staff or residents of R1 falling from the 7th floor.

Based on today's interview and documentation received, LPA has determined, no further action is needed at this time, and due to the police deeming no foul play. Police report # 23-75173

Exit interview and copy of report provided.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
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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