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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802472
Report Date: 12/29/2022
Date Signed: 12/29/2022 02:34:51 PM


Document Has Been Signed on 12/29/2022 02:34 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. #250
WOODLAND HILLS, CA 91364



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: 35DATE:
12/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Sean Beharry, Backup AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted an unannounced case management visit to issue deficiencies discovered while investigating multiple complaints. LPA Olson reviewed records and interviewed staff on 12/21/22, 12/22/22, and 12/23/22. LPA Olson interviewed residents on 12/29/2022. During today’s visit, LPA Olson met with Sean Beharry, Backup Administrator and explained the reason for the visit.

Resident 1 (R1) reported on 3/25/2022 that on 3/16/2022, Staff 1 (S1) gave R1 a shower and inappropriately touched R1. Based on CCL’s records of incident reports received, the facility did not submit an incident report for this incident. LPA asked the Administrator for a copy of the incident report, but was told the former administrator had them and they could not provide the incident report or proof it was sent in. LPA also informed Administrator that CCL did not receive the other 2 incidents regarding R1.

Additionally, on 12/29/2022 LPA asked to review Staff 2 (S2)’s file for another complaint alleging abuse. At around 12 PM Administrator stated they had access to the staff files but would not be available to provide LPA the file until 4-5 days later. Administrator later stated they will try to have someone drop them off by the end of the day. As of 2:30 PM the file is still not here and Staff files were not readily available to LPA within a reasonable amount of time.

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

Exit interview conducted, copy of report and appeal rights emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
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 12/29/2022 02:34 PM - It Cannot Be Edited

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. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: VENTURA GRAND CHATEAU
FACILITY NUMBER: 565802472

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2023
Section Cited

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87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency…seven days of the occurrence of…Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents...
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Administrator agreed to provide a written statement of acknowledgement and understanding of 87211.
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This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section, when an incident report for 3 seperate incidents was not submitted to CCL, which posed a potential health and safety risk to residents in care.
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Type B
01/05/2023
Section Cited

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87412(f) Personnel Records. All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement was not met as evidenced by:
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Administrator agreed to provide a written statement of acknowledgement and understanding of 87412.
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Based on observation and interview, the licensee did not comply with the above cited section when S2’s personnel record was not available to CCL, which posed a potential health and safety risk to residents 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
LIC809 (FAS) - (06/04)
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