565802472-4-14-2022-29-AS-KHEN-CDHU4L-20220415151515

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802472
Report Date: 04/12/2022
Date Signed: 04/14/2022 09:29:19 AM

Unsubstantiated

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
12/15/2020 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20201215111706

FACILITY NAME:	VENTURA GRAND CHATEAU		FACILITY NUMBER:	565802472
ADMINISTRATOR:	MARK DEN PERALTA		FACILITY TYPE:	740
ADDRESS:	5430 TELEGRAPH ROAD		TELEPHONE:	(805) 642-2567
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	49	CENSUS: 36	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	11:29 AM
MET WITH:	Amy Vizzo		TIME COMPLETED:	11:51 AM

ALLEGATION(S):

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Staff physically abused Resident #1 (R1)

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit on 04/12/2022 to deliver findings for the above allegation. The initial visit was conducted on 12/17/2020 by LPA Brian Balisi virtually, and a subsequent visit was conducted on 04/08/2022 by LPA Camara. During today’s visit, the LPA reviewed the findings over the phone with the facility administrator Mark Peralta and he indicated medication technician Sue Vizzo was authorized to sign the report.

On 12/15/2020, the Department received a complaint regarding the allegation Resident #1 (R1) was physically abused by facility staff. On 12/17/2020, between 12:30 p.m. and 2:20 p.m., LPA Balisi conducted the initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically. The LPA conducted an interview and physical plant tour via video call with facility assistant administrator Mike Dimaguila. The LPA requested copies of pertinent documents relevant to the investigation and noted further investigation would be required. (continued 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20201215111706

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: 04/12/2022

NARRATIVE

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During LPA Camara’s visit to the facility on 04/08/2022 between 09:15 a.m. and 12:17 p.m., LPA Camara conducted a brief plant tour at 9:15 a.m., interviewed Staff 1 (S1) at 9:25 a.m., interviewed Resident 1 (R1) at 9:35 a.m., interviewed Resident 2 (R2) at 9:41 a.m., interviewed Staff 2 (S2) at 9:50 a.m., reviewed records at 10:12 a.m., and interviewed the administrator at 11:11 a.m. LPA obtained copies of pertinent facility records.

On 04/06/2022 at 3:37 p.m., LPA Camara conducted a telephonic interview with the complainant. On 04/11/2022, LPA Camara conducted a telephonic interview with Staff 3 at 12:24 p.m. On 04/11/2022, LPA Camara received and reviewed a copy of the police report regarding this incident.

Information gathered reflects R1 was initially admitted to the facility on 08/01/2019. R1 shares a room at the facility with R2. On 12/11/2020, R1 removed photos of R1 and R2 which were displayed in a public area of the facility. R1 took the photos and hid them in their room. Staff 4 (S4) went to their room and requested R1 return the photos. R1 became angered and physically attacked S4. R1 grabbed S4 by the wrists and then hit S4 in the face. S2 and S3 responded to the commotion and were also physically pushed by R1. S3 called the police as R1 would not calm down and other residents did not feel safe. The police responded and requested an evaluation by the behavioral health crisis team.

The police report indicated that R1 was the suspect in their investigation and S4 was the victim. In addition, the police report indicated R1 also attacked S2 and S3 but there were no injuries noted. However, injuries were observed on S4. The police report also indicated R1 violated the law, but was not arrested. An interview was conducted with one of the crisis team clinicians who had responded with the police. It was determined R1 struck S4 out of anger rather than a mental health crisis, so R1 was not placed on a 5150 hold or taken to the hospital. Although R1 claimed they were pushed down by staff, there were no injuries observed on R1.

In an interview with R1, no accusations were made regarding abuse nor did R1 recall this incident in which police were called to the facility. R1 said they (R1 and R2) are safe at the facility and staff are good to them.

Based on the police report, R1 was the aggressor in this incident and there was no indication R1 experienced any injuries. In addition, R1 stated they (R1 and R2) feel safe at the facility and staff are good to them. As a result, there is insufficient evidence to confirm that R1 was physically abused by facility staff; therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and a copy of the report issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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