565850093-6-11-2021-29-AS-JROS-C3W4P3-20210611191602

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850093
Report Date: 06/11/2021
Date Signed: 06/11/2021 07:16:40 PM

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 VILLA ASSISTED LIVING		FACILITY NUMBER:	565850093
ADMINISTRATOR:	WARD-MICHAYLUK, EVANGELINE		FACILITY TYPE:	740
ADDRESS:	3482 LOMA VISTA ROAD		TELEPHONE:	(818) 359-9447
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	49	CENSUS: 23	DATE:	06/11/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:14 AM
MET WITH:	Evangeline Ward-Michayluk		TIME COMPLETED:	06:18 PM

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Licensing Program Analyst (LPA) JoAnn Rosales made a Pre-licensing visit to the facility. This application is a change of ownership from Treacy Villa #561703345. Component III was conducted in conjunction with this pre-licensing visit.

Facility has 2 private bedrooms, 23 shared bedrooms, 1 staff room, 16 bathrooms and 3 shower rooms. During facility tour at 10:48 am and 12:04 pm with staff Jennifer Sharma hot water temperature tested at 131.7 and 126 degrees Fahrenheit in resident bathrooms. Licensee/Representative Craig Michayluk turned down water heater temperature during facility visit. During facility tour at 10:22 am LPA observed windex, glue, scissors, rubbing alcohol and room spray in an unlocked Administrators office. Staff locked office door during facility visit. The common areas were appropriately furnished and lighting was adequate. Facility maintains a comfortable temperature. During facility tour at 10:52 am LPA observed hair spray, shaving cream, 20 volume cream developer and concentrated bleach in an unlocked beauty salon. Staff locked beauty salon during facility visit. During facility tour starting at 11:00 am LPA did not observe mattress pads on any of the residents beds. There are DVD's, arts and crafts, bingo, painting, balloon toss for activities. Resident medications are kept in a locked medication room. During facility tour at 11:05 am LPA observed hair spray and hair conditioner, lotion and barrier cream in room #401's bathroom accessible to residents. Resident and staff records are kept in the Administrators office. There is a sufficient supply of clean linens. During facility tour at 11:13 am LPA observed rust and mold in shower room floor and walls, shampoo and conditioner accessible to residents. Food storage and prep areas are clean and there is a sufficient supply of dishes, glasses and utensils. The freezer and refrigerator are at proper temperature range. During facility tour at 11:21 am LPA observed shower gel in the dining room accessible to residents. During facility tour at 11:36 am LPA observed a razor in room #411's shared bathroom accessible to residents. During facility tour at 11:44 am LPA did not observe a 7 day supply of non-perishable fruit as the facility had 5 large cans of fruit.

Continued on 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

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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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 VILLA ASSISTED LIVING	FACILITY NUMBER: 565850093
	VISIT DATE: 06/11/2021

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During facility tour at 11:53 am LPA observed a hole in the wall in room #101. During facility tour at 12:05 pm LPA observed a knife in room #105's refrigerator accessible to residents. During facility tour at 12:18 pm LPA observed deodorant in room #202's bathroom accessible to residents. During facility tour at 12:19 pm LPA observed shampoo in Shower room B. Laundry equipment, telephones, emergency lighting were present. LPA observed a complete first aid kit. During facility tour LPA observed surveillance cameras in common areas of the facility. Fire clearance is approved for 49 non-ambulatory residents of which 14 may be bedridden in bedrooms #105, 201, 202, 203, 204, 205, 207, 209, 301, 302, 303, 304, 305 and 411. Deficiencies cited under existing facility Treacy Villa #561703345.

The physical plant is not in compliance with Title 22 regulations at this time.

The following needs to be completed/proof submitted prior to the facility being licensed:

1. Mattress pads for resident beds.

2. 7 day supply of non-perishable fruit.

3. Updated facility sketch changing Nurses station to Receptionist, TV Room to Storage Room and Staff B.R. to Medication Room.

4. Deficiencies cited under existing facility Treacy Villa #561703345 cleared.

Exit interview conducted, todays reports were reviewed and emailed to the Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

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