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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802472
Report Date: 10/14/2020
Date Signed: 10/15/2020 08:31:57 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2020 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20200501164345
FACILITY NAME:VENTURA GRAND CHATEAUFACILITY NUMBER:
565802472
ADMINISTRATOR:MARK DEN PERALTAFACILITY TYPE:
740
ADDRESS:5430 TELEGRAPH ROADTELEPHONE:
(805) 642-2567
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:49CENSUS: 42DATE:
10/14/2020
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Mark PeraltaTIME COMPLETED:
10:38 AM
ALLEGATION(S):
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Staff did not seek medical attention in a timely manner (for R1)
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a subsequent complaint investigation to deliver final investigation findings telephonically with Administrator Mark Peralta due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures.

Concerns were that staff did not seek medical attention in a timely manner for Resident #1 (R1). An interview with R1’s family member on 5/18/2020 at 2:07 pm revealed that on 4/29/2020, they called the facility to schedule a facetime visit with R1 and was told by S1 that R1 had a fever and was in bed. R1’s family member stated they called the facility back around 6:30 pm, requested staff to take R1’s temperature, and was told R1 had a temperature of 100.3 degrees Fahrenheit.

On 4/30/2020, R1’s family member was told by facility staff that R1 was seen by Home Health (HH). R1’s

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20200501164345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VENTURA GRAND CHATEAU
FACILITY NUMBER: 565802472
VISIT DATE: 10/14/2020
NARRATIVE
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family member stated R1 had an appointment with their physician on 5/1/2020; however, facility staff did not want R1 to leave the facility. R1’s family member stated they decided to have a phone conference with R1’s physician, facility staff and themselves. During the phone conference, R1’s physician wanted R1 to go to the emergency room, as they were concerned about R1 having blood clots.

An interview with R1’s physician on 5/4/2020 at 3:16 pm revealed that on 4/30/2020 around 5 pm, they told facility staff if R1 got worse and was spiking fevers, they needed to send R1 to the hospital. R1’s physician stated that they had an appointment to see R1 on 5/1/2020 and was told by R1’s family member that the facility would not let R1 leave the facility to go to the appointment. R1’s physician stated during their telephone conference with facility staff on 5/1/2020 they demanded that facility staff to take R1 to the emergency room. Based on the information obtained during the course of the investigation this allegation is deemed substantiated at this time.

A telephonic exit interview was conducted with the Administrator, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20200501164345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VENTURA GRAND CHATEAU
FACILITY NUMBER: 565802472
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2020
Section Cited
CCR
87465(a)(2)
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87465 Incidental Medical and Dental Care (a)(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation...In providing transportation the licensee shall do so directly or make arrangements for this service.

This requirement is not met as evidenced by:
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Administrator stated that he will provide documentation of staff training regarding meeting residents medical and dental care needs.
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Based on interviews, the licensee did not comply with the section cited above as R1 was not provided assistance with medical needs as the facility did not allow R1 to go to their medical appointment and R1's physician demanded facility staff to take R1 to the emergency room.
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2020 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20200501164345

FACILITY NAME:VENTURA GRAND CHATEAUFACILITY NUMBER:
565802472
ADMINISTRATOR:MARK DEN PERALTAFACILITY TYPE:
740
ADDRESS:5430 TELEGRAPH ROADTELEPHONE:
(805) 642-2567
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:49CENSUS: 42DATE:
10/14/2020
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Mark PeraltaTIME COMPLETED:
10:38 AM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff neglect resulting in resident #1 (R1) developing an infection (cellulitis)
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) JoAnn Rosales conducted a subsequent complaint investigation to deliver final investigation findings telephonically with Administrator Mark Peralta due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures.

Concerns were that staff neglect resulted in R1 developing an infection. Interview with staff #1 (S1) on 5/18/2020 at 12:56 pm revealed that they observed red streaks on R1’s leg going up to the groin around 8:30 am on 4/30/2020 and had a temperature of 103 degrees. Interview with R1’s physician on 5/4/2020 at 3:16 pm revealed that on 4/30/2020 around 5 pm they received a message from the facility about a rash on R1’s leg. R1’s physician stated that they told the facility if R1 got worse and was spiking fevers they needed to send R1 to the hospital. R1’s physician stated during a telephone conference with facility staff on 5/1/2020 they demanded that they take R1 to the emergency room. S1 stated that they notified R1’s responsible

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20200501164345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VENTURA GRAND CHATEAU
FACILITY NUMBER: 565802472
VISIT DATE: 10/14/2020
NARRATIVE
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person who had indicated that they would notify R1’s physician. S1 stated that R1 was assessed by Home Health. A review of R1’s records on 5/19/2020 revealed that on 4/29/2020 R1 was running a slight fever and was given Tylenol. On 4/29/2020 R1’s family member was notified about the fever. On 4/29/2020 Home Health saw R1 and took a urine sample and requested R1 be monitored for fever. On 4/30/2020 R1 had a temperature of 103 at 2:30 am cold compress and Tylenol was given bringing fever down to 101 at 3:30 am fever went back to 103 at 5:30 am. 4/30/2020 staff spoke with R1’s family member and notified doctor waiting on response for antibiotic told doctor everything about fever took pictures and sent it to R1’s family member. Based on the information obtained during the course of the investigation the allegation is deemed unsubstantiated at this time.

A telephonic exit interview was conducted with the Administrator, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5