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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801810
Report Date: 11/17/2021
Date Signed: 11/17/2021 05:57:37 PM

Document Has Been Signed on 11/17/2021 05:57 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 TOWNEHOUSEFACILITY NUMBER:
565801810
ADMINISTRATOR:EVAN GRANUCCIFACILITY TYPE:
740
ADDRESS:4900 TELEGRAPH ROADTELEPHONE:
(805) 642-3263
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 566CENSUS: 218DATE:
11/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Evan GranucciTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Case Management - Deficiencies visit at the facility. LPA met with Administrator Evan Granucci.

During facility tour with Administrator on 11/17/21 at 11:38 am LPA observed 2 bottles of laundry detergent in the 4th floor laundry room accessible to residents. LPA did not observe any residents in the laundry room. Administrator stated that a resident must have left them in the laundry room.

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

Civil penalty assessed in the amount of $250.00.

Exit interview conducted, todays reports, civil penalty and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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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Document Has Been Signed on 11/17/2021 05:57 PM - It Cannot Be Edited


Created By: Joann Rosales On 11/17/2021 at 03:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VENTURA TOWNEHOUSE
FACILITY NUMBER: 565801810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/18/2021
Section Cited

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as toxic substances were observed accessible to residents which posed an immediate health 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 Margaryan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2021


LIC809 (FAS) - (06/04)
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