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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802472
Report Date: 02/22/2024
Date Signed: 02/22/2024 03:29:01 PM


Document Has Been Signed on 02/22/2024 03:29 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:MICHAEL DIMAGUILAFACILITY TYPE:
740
ADDRESS:5430 TELEGRAPH ROADTELEPHONE:
(805) 642-2567
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:49CENSUS: 37DATE:
02/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sean Beharry TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Martha Arroyo and Valeria Conway conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20230608141637). The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation.

During the complaint investigation of complaint # 29-AS-20230608141637, the following deficiency was observed: On 09/04/2022, Resident #1 (R1) had an unwitnessed fall in the dining room after R1’s wheelchair wheels unlocked. R1 was found next to their wheelchair in the dining room with a large bump ecchymosis (bruise) on their left forehead and a bruise with swelling on their right knee lower shin area. Hospice instructed facility staff to place R1 on bed rest and ice both sites three times a day. However, records review revealed that facility did not submit an incident report (LIC 624) to Community Care Licensing (CCL) reporting the unusual incident for R1.


Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).

Exit Interview. Citation issued. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
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 02/22/2024 03:29 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: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/29/2024
Section Cited
CCR
87211(a)(1)(D)

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(a)Each licensee shall furnish to the licensing agency reports…within seven days of the occurrence of any of the events specified in (A) through (D). (D)Any incident which threatens the welfare, safety or health of any resident. This requirement was not met as evidenced by:
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The Licensee will read regulation 87211 on Reporting Requirements and submit a statement of understanding to CCL no later than 12/29/2024.
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Based on record review, the licensee did not comply with the section cited above as, R1 had an unwitnessed fall causing a forehead bruise and right knee swelling which prompt hospice to have R1 placed on bed rest, which posed a potential health and safety risk to resident 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
LIC809 (FAS) - (06/04)
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