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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802472
Report Date: 12/07/2021
Date Signed: 12/08/2021 09:36:29 AM

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: 41DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Sean BeharryTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 1:33 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with staff member Sean Beharry and discussed the reason for the visit. Entrance interview conducted.

The LPA, along with Staff member, toured the physical plant areas inside and outside at 1:40 p.m. to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 25 (twenty-five) total bedrooms for resident use – seventeen (17) are shared rooms and eight (8) are private rooms.

RESTROOMS: Public and resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed sufficient amounts of soap and paper products in each restroom. Hand washing posters were not observed in any restroom. LPA advised staff to post the required postings in all restrooms. Water temperature were also checked in five (5) random rooms and restrooms, 4 out of the 5 restrooms were between 105.0 and 120.0 degree F. LPA advised staff to turn up the water temperature in the one (1) public restroom as water temperature read 96.3 degrees F.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed some required postings in the common hallway. LPA advised to add additional posting in other parts of the buildings for consistency. Fire extinguishers were observed to be serviced within the last year.

Continued on LIC 809 C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
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)
Page: 1 of 3
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
VISIT DATE: 12/07/2021
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The courtyard has an outdoor area equipped with furniture for resident use. There were no bodies of water noted. Laundry room and storage room contained a locked storage cabinet for laundry supplies. A second (2) storage room was observed locked and contained the emergency food supply. Smoke detectors were tested and observed to be in good operation at the time of visit.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the staff member regarding the facility’s infection control practices at 2:50 p.m. There is only one (1) entry into the facility. Upon entry, the facility has a central point for symptom screening. LPA noted that the facility is allowing visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The LPA also observed an adequate supply of medication. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:


- Post hand washing posters in all restrooms.
- Post PINs and educate staff, residents, and families on changing policies and procedures from the Department
- Post COVID - 19 and cough etiquette poster around the community.

1 citations were issued during today’s visit. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. Copy of the report and appeal rights provided to admin via email.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
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
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 12/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as 1 out of 5 random restroom tested for water temperature was at 96.3 degree F which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2021
Plan of Correction
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Admin will increase water temperature for the restroom not in compliance. Admin will test water temperature and will send water temperature log for 2 days, testing throughout the day, to LPA Ascencio via email : angel.ascencio@dss.ca.gov.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3