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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802472
Report Date: 04/12/2022
Date Signed: 04/14/2022 10:46:16 AM


Document Has Been Signed on 04/14/2022 10:46 AM - 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: 36DATE:
04/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:Amy VizzoTIME COMPLETED:
11:51 AM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced Case Management – Deficiencies visit on 04/12/2022, in conjunction with complaint control # 29-AS-20201215111706. LPA went over this report with facility administrator Mark Peralta over the phone and he authorized medication technician Amy Vizzo to sign the report.

During the course of the investigation of the above noted complaint, it was discovered the administrator failed to report an incident that took place on 12/11/2022 involving R1 in which the police and behavioral health were called to the facility.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted, today's reports and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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 04/14/2022 10:46 AM - 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: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2022
Section Cited

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the findings, and treatment if
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occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by:
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Police were called to the facility for an incident which took place on 12/11/2020, however the incident was never reported to CCL.

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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: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
LIC809 (FAS) - (06/04)
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