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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801810
Report Date: 07/28/2021
Date Signed: 07/28/2021 07:02:13 PM

Document Has Been Signed on 07/28/2021 07:02 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: 214DATE:
07/28/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:48 AM
MET WITH:Evan GranucciTIME COMPLETED:
06:11 PM
NARRATIVE
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This Case management visit was conducted to address the deficiencies noted during complaint control # 31-AS-20210721160917 investigation visit conducted on 7/28/21.

During facility tour with Administrator on 7/28/21 starting at 11:48 am LPA observed germicidal disposable wipes, TB-Cide Quat cleaner/deodorizer/disinfectant, knife, aller-flo nasal spray and scissors in an unlocked 3rd floor office accessible to residents. At 1:16 pm LPA observed WD-40 on a maintenance cart in the 3rd floor hallway accessible to residents.

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


Exit interview conducted, todays reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2021
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 07/28/2021 07:02 PM - It Cannot Be Edited


Created By: Joann Rosales On 07/28/2021 at 05:05 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: 07/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2021
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Administrator locked 3rd floor office door during facility visit. Administrator stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(1) to CCL by 7/29/21.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as a knife and scissors were observed accessible to residents which posed an immediate health risk to persons in care.
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Type A
07/29/2021
Section Cited
CCR87705(f)(2)

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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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Administrator locked 3rd floor office door during facility visit. Maintenance staff arrived and kept maintenance cart under their supervision. Administrator stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(2) to CCL by 7/29/21.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as over-the-counter medication, toxic substances, cleaning supplies and disinfectants 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2021


LIC809 (FAS) - (06/04)
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