565850093-6-29-2021-29-AS-KHEN-CGQVPN-20220727163701

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850093
Report Date: 06/29/2021
Date Signed: 06/29/2021 06:00:15 PM

Substantiated

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
06/28/2021 and conducted by Evaluator Joann Rosales

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210628115658

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: 24	DATE:	06/29/2021
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Evangeline Ward-Michayluk		TIME COMPLETED:	04:43 PM

ALLEGATION(S):

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Facility did not arrange transportation for resident's medical/dental care

INVESTIGATION FINDINGS:

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During today's visit Licensing Program Analyst (LPA) JoAnn Rosales toured the facility with staff Jennifer Sharma, reviewed random resident records, interviewed random staff and obtained copies of pertinent documents.

Concerns were that the facility is not arranging for transportation for residents medical/dental care. Interview with staff #1 (S1) starting at 10:54 am revealed that the facility used to make the appointments and take the residents to their medical/dental appointments. S1 stated that the residents responsible persons are scheduling their own medical/dental appointments and are also arranging for the transportation. Interview with Administrator revealed that they told resident #1 (R1)'s conservator that their van was broken so they could not provide transportation for R1's medical appointment. Administrator stated that they told R1's conservator that they would have to make transportation arrangements for R1's medical appointment.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 29-AS-20210628115658

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 VILLA ASSISTED LIVING	FACILITY NUMBER: 565850093
	VISIT DATE: 06/29/2021

NARRATIVE

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Administrator stated that the van has not been working since August 2020. A review of R1's records starting at 11:47 am revealed that they will plan, arrange and/or provide transportation to medical and dental appointments as follows: we will make the appt, we will take resident. Based on the information obtained during the course of the investigation this allegation is deemed substantiated at this time.

Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20210628115658

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 VILLA ASSISTED LIVING	FACILITY NUMBER: 565850093
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 07/09/2021 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a)(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation...In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated that they will provide documentation of training regarding regulation 87465 from an outside vendor to CCL by 7/9/21.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above as the facility did not make transportation arrangements for R1's medical appointment which poses a potential personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

LIC9099 (FAS) - (06/04)

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