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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802472
Report Date: 01/20/2023
Date Signed: 01/20/2023 10:06:34 AM

Substantiated


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
11/07/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20221107092639
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: 38DATE:
01/20/2023
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Amy VizzoTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Resident was physically assaulted by staff, resulting in bruising
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to deliver the findings for the above allegation. The LPA met with staff Amy Vizzo and explained the reason for the visit. Findings were delivered to Administrator Michael Dimaguila over the phone.

On 11/07/2022, the Department received a complaint, alleging that Staff #1 (S1) hit Resident #1 (R1), which resulted in bruising. Community Care Licensing Division’s Investigations Branch (IB) Investigator Peter Zertuche was assigned to the case. On 11/8/2022, the LPA interviewed staff at 12:00 p.m., 12:35 p.m., 1:28 p.m., 1:40 p.m., and interviewed Staff #1 (S1) at 2:15 p.m. In addition, the LPA, S1, and three (3) officers from the local police department toured the facility dining room at 2:45 p.m., and reviewed video footage of the incident at approximately 3:00 p.m. Investigator Zertuche interviewed staff on 11/09/2022 at 11:00 a.m., and on 12/08/2022 at 11:00 a.m., 11:15 a.m., 11:30 a.m., 11:45 a.m., and 12:00 p.m.; interviewed R1’s responsible party on 11/15/2022 at 3:00 p.m.; interviewed a resident on 12/08/2022 at 10:30 a.m.; and, interviewed Resident #1 (R1) at 10:45 a.m. Investigator Zertuche also requested police records pertinent to the case.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
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 3
Control Number 29-AS-20221107092639
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: 01/20/2023
NARRATIVE
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It was alleged that on 11/02/2022 at approximately 7:45 a.m., a physical altercation took place between S1 and R1. Multiple witnesses and video footage confirmed that on 11/02/2022, S1 attempted to grab a plate of food out of R1’s hands. Witnesses confirmed that S1 shoved R1 in an attempt to force R1 to sit down and witnesses reported that S1 slapped R1 across the face with an open hand. Video footage captured S1 and R1 shoving one another, and another staff walks into the frame to assist in de-escalating the situation. S1 grabbed the R1 by the right arm, while the other staff grabbed R1’s left arm, and walked R1 out of the dining room and towards R1’s room. Footage showed that S1’s hand was on the back of R1’s neck and their other hand was gripping R1’s forearm while walking R1 to the room. It appeared that S1 was applying pressure to R1’s neck, as R1’s body and face was tilted towards the floor as they were walking. Footage revealed that S1 pushed R1 into their room, and S1 was seen walking away from R1’s room. R1 suffered significant bruising on their right forearm from the altercation.

Information obtained from interviews with S1 negated claims that S1 physically assaulted R1. S1 alleged that they were ‘blocking’ hits from R1 and claimed that they accidentally scrapped R1 on the forearm when they were walking R1 to the room. S1 did not admit to slapping R1. Interviews confirmed that this incident was not immediately reported to R1’s responsible party, with many concluding that they believed the Administrator would contact R1’s responsible party or R1’s primary care physician. It was later revealed that R1’s responsible party was notified when they were contacted by the local police department.

During the initial visit conducted on 11/08/2022, three (3) local police officers arrived at the facility to speak to S1 and to review and obtain video footage. In that visit, the LPA, S1, and the three (3) officers reviewed the video footage from the 11/02/2022 incident. It was later revealed that as a result of the video footage and witness statements, S1 was arrested on 11/08/2022 and charged with elder abuse. Per the current Administrator, S1 was placed on administrative leave.

Based on the information obtained from witnesses and video footage, there is sufficient evidence to support the claim that R1 was physically assaulted by S1, resulting in bruising. This allegation is deemed Substantiated at this time.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 9099-D). Exit Interview Conducted. Failure to correct the deficiencies may result in civil penalties. A Civil Penalty in the amount of $500 was assessed during today's visit. Appeal Rights Discussed. A Copy of Report Issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 29-AS-20221107092639
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: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following....: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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The Administrator agreed to do the following:
1. Schedule training on Personal Rights for all staff. Training must be conducted by an outside vendor. Confirmation of the scheduled training must be sent to CCL by 1/23/2023, end of day.
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This requirement is not met as evidenced by:
Based on interviews and video footage, the licensee did not comply with the section cited above, as S1 physically assaulted R1, resulting in R1 sustaining bruises, which poses an immediate health and safety risk to residents in care.
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Training must be conducted within two weeks' time. Submit confirmation of training to CCL, then subsequently submit sign in sheet and any training materials in the next 14 days.

Civil penalty of $500 assessed due to a violation which caused injury.
CCR
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3