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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850093
Report Date: 07/08/2021
Date Signed: 07/08/2021 05:21:02 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 LIVINGFACILITY NUMBER:
565850093
ADMINISTRATOR:WARD-MICHAYLUK, EVANGELINEFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA ROADTELEPHONE:
(818) 359-9447
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:49CENSUS: 22DATE:
07/08/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Evangeline Ward-Michayluk and Craig MichaylukTIME COMPLETED:
04:25 PM
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A virtual Office Meeting was conducted to discuss concerns that were brought to our attention regarding the change in ownership from Treacy Villa #561703345.

Present at today’s meeting were: Jill Nakata Regional Manager (RM), Kristin Heffernan Licensing Program Manager (LPM), JoAnn Rosales Licensing Program Analyst (LPA), Evangeline "Joy" Ward-Michayluk Administrator and Craig Michayluk Licensee/Representative.

RM discussed staffing and communication with residents and their responsible persons and making sure that what is being communicated is cohesive. RM requested Administrator to submitted a current LIC500 Personnel Record. LPM discussed the visitation policy suggesting that they follow the Provider Information Notice (PIN) 21-17.2-ASC dated 5/14/21. Licensee/Representative agreed to follow the Provider Information Notices including revising their visitation policies. LPA to provide a copy of PIN 21-17.2-ASC to Administrator and Licensee/Representative. LPM discussed Health and Safety Code 1569.655 regarding any rates increases for residents. Licensee/Representative agreed to follow Health and Safety Code 1569.655 and provide residents and/or their responsible party a written 60 day notice. LPA to provide a copy of Health and Safety Code to Administrator and Licensee/Representative. LPM discussed changes in residents Pharmacies, Physical Therapists, Home Health, Hospice any other Providers. Licensee/Representative agreed to notify residents and their responsible persons prior to making any changes in residents Providers. LPM discussed the facility's transportation policy. Administrator stated that they have made arrangements with a 3rd party transportation company to provide transportation for residents. LPM discussed exceptions and waivers that will need to be submitted under the new license.

Exit interview conducted, today's report was reviewed and emailed to the Administrator and Licensee/Representative.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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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