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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801810
Report Date: 12/06/2021
Date Signed: 12/07/2021 02:30:45 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/07/2021 02:30 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: 219DATE:
12/06/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Evan GranucciTIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Case Management - Annual Continuation visit. LPA met with Administrator Evan Granucci. *This is an amended report to make corrections noted after further review of the report*.

A physical plant tour was conducted to ensure there are no health and safety hazards. During facility tour at 11:11 am with Administrator LPA observed a housekeeping cart outside of room #208 with cleaner and degreaser and bleach germicidal cleaner accessible to residents. Administrator located housekeeping staff #1 (S1) in a resident laundry room down the hall. During facility tour at 11:21 am with Administrator LPA observed a housekeeping cart outside of room #638 with stainless steel cleaner, toilet cleaner, comet and cleaner and degreaser accessible to residents. Administrator located housekeeping staff S2 in room #638. During facility tour at 11:32 am with Administrator LPA observed a housekeeping cart outside of room #53 with furniture polish, stainless steel cleaner, toilet cleaner, comet, glass cleaner, floor cleaner and bleach germicidal cleaner accessible to residents. Administrator located housekeeping staff S3 inside room #53. Administrator stated that the housekeeping staff normally take the chemicals with them inside the resident rooms while they are cleaning. LPA reviewed random resident medications. During a review of resident medications at 12:11 pm with S4 LPA observed that resident #1 (R1) is prescribed gabapentin 300 mg 1 capsule by mouth at bedtime. R1 was not given the medication on 12/3/21 as it was still in the bubblepack. The admin history for R1's medication indicates that R1 was given their medication on 12/3/21 at 8:38 pm. LPA observed first aid kit complete. LPA reviewed random staff records.

Due to computer issues LPA is unable to amend the 10/21/21 Required 1-year visit report citation 87465(h)(2) Incidental Medical and Dental Care Services. The citation of 87465(h)(2) is being amended to 87705(f)(2) Care of Persons with Dementia and is being cited on this Case Management visit report.

Continued on 809C
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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 12/06/2021 04:06 PM - It Cannot Be Edited


Created By: Joann Rosales On 12/06/2021 at 02:40 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: 12/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2021
Section Cited
CCR
87705(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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Housekeeping staff removed and secured toxic substances during 12/6/21 facility visit. Administrator locked R1 and R2's bedroom door during 10/21/21 facility visit. Administrator stated that they will provide documentation of scheduled staff training to CCL by 12/8/21.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as medications and toxic substances were observed accessible to residents which posed an immediate health risk to persons in care.
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Type A
12/07/2021
Section Cited
CCR87465(a)(5)

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87465 Incidental Medical and Dental Care Services(a)(5) The licensee shall assist residents with self-administered medications as needed.


This requirement is not met as evidenced by:
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Administrator stated that they will provide dodocumentation of scheduled staff medication training to CCL by 12/8/21 and documentation of training on 12/16/21.
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Based on medication review, the licensee did not comply with the section cited above in 1 out of 3 resident medications which poses 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: 12/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2021


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VENTURA TOWNEHOUSE
FACILITY NUMBER: 565801810
VISIT DATE: 12/06/2021
NARRATIVE
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Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Civil penalties issues in the amount of $250.00.

Exit interview conducted. Today's 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: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021
LIC809 (FAS) - (06/04)
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