565850083-1-31-2022-29-AS-ASMH-CB7T9M-20220131133206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850083
Report Date: 01/31/2022
Date Signed: 01/31/2022 01:32:37 PM

Document Has Been Signed on 01/31/2022 01:32 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:	LA VENTANA TREATMENT PROGRAMS		FACILITY NUMBER:	565850083
ADMINISTRATOR:	VOLNER, SHARON		FACILITY TYPE:	772
ADDRESS:	1508 BEREA CIRCLE		TELEPHONE:	(818) 584-5615
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY: 6		CENSUS: 5	DATE:	01/31/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Steve Zamarripa and Sharon Volner		TIME COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced at 9:35 a.m. to conduct a required one year/post-licensing annual inspection. The LPA met with staff and explained the reason for the visit. Licensee Representative Steve Zamarripa, Director of Nursing Wendy McCain, and Administrator Sharon Volner arrived shortly thereafter. Entrance interview conducted. The LPA toured the two-story dwelling inside and outside with staff to ensure there were no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen knives and cleaning supplies are stored locked and inaccessible in the hallway closet. Kitchen appliances were clean and all appeared functional. The facility has a sufficient supply of perishable and non-perishable food. At 9:42 a.m., the hot water in the kitchen registered at 153.7 degrees Fahrenheit. BEDROOMS: The facility has three shared bedrooms for clients. All rooms were furnished appropriately with beds, nightstands, lamps, chests of drawers, chairs and closet space. Lighting in the rooms was adequate. BATHROOMS: There are five bathrooms; two on the first floor and three on the second floor. Two out of the three client rooms have an attached client bathroom. At 9:52 a.m., the hot water in the first floor bathroom registered at 165.2 degrees Fahrenheit. COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. There is a fireplace in the Group Room but was observed without any tools. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested at 11:01 a.m. and were operational at the time of the visit. The fire extinguishers were fully charged.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022

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 01/31/2022 01:32 PM - It Cannot Be Edited

Created By: Ashley Smith On 01/31/2022 at 12:18 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LA VENTANA TREATMENT PROGRAMS	FACILITY NUMBER: 565850083
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

81019(e)(1)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department; or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, as there were four staff (S1, S2, S3, S4) working whom were not associated to this facility, which poses an immediate health and safety risk to clients in care.
	POC Due Date: 02/01/2022
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: 1. Ensure that S1, S2, S3, and S4 are associated to the facility prior to allowing them to return to work. Proof to be submitted to the LPA no later than 2/1/2022. Civil penalties assessed.

Type A

Section Cited

CCR

81088(e)(1)

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as the water temperature registered above 150 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/02/2022
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Adjust the water temperature. Inform the LPA when this has happened 2. Complete a five-day water temperature log. Submit temperature log no later than 2/7/2022

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 Pfannenstiel

LICENSING EVALUATOR NAME:

Ashley Smith

LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022

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: LA VENTANA TREATMENT PROGRAMS	FACILITY NUMBER: 565850083
	VISIT DATE: 01/31/2022

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MEDICATIONS: Medications are kept locked and inaccessible in a closet in the hallway.

RECORDS: Records records review began at 10:05 a.m.; clients records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. The LPA compared the staff schedule for this location to the Guardian Background Check System and identified that four staff were working without a clearance transfer to this facility.

THERAPY AND STAFF: The facility is equipped with an Isolation Room, a Group/Activity Room, and a Staff Room on the first floor. There is a small group room on the 2^nd floor. The above-mentioned rooms can be utilized for individual and group therapy. Staff and client files are stored electronically, however the facility also has physical client files.

GARAGE AND GROUNDS: The garage is designated as the Recreational Room. The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs where clients can sit. There is a storage shed in the backyard. There is an in-ground pool, which is kept locked and is appropriately fenced per regulation.

INFECTION CONTROL: The facility has a central entry point for symptom screening and sanitation station for staff, clients and visitors. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The LPA observed signs throughout the space that promoted good hand hygiene, signs and symptoms of COVID-19, droplet precautions, and proper mask usage. The facility’s policies and procedures as it pertains to infection control are adequate.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):
Exit interview conducted, today's reports and appeal rights were reviewed and issued. Civil Penalties assessed.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022

LIC809 (FAS) - (06/04)

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