565850093-2-6-2023-29-AS-KBUY-CP5S69-20230217123536

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850093
Report Date: 02/06/2023
Date Signed: 02/06/2023 11:58:43 AM

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
07/09/2021 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-NP-20210709071914

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:	ZIP CODE:	93003
CAPACITY:	49	CENSUS: 18	DATE:	02/06/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Evangeline Ward-Michayluk		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility did not inform responsible party regarding change in resident’s physical therapy

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Joy Ward-Michayluk, Administrstor.
Concerns were that the facility did not inform resident #1 (R1)’s responsible party regarding change in resident’s physical therapy to Innerjoy Home Health. On 7/14/21 starting at 10:53 am interviews were conducted with staff, Administrator and residents. On 7/29/22 starting at 10:55 am interviews were conducted with resident family members. On 8/10/21 starting at 1:59 pm interviews were conducted with staff from Los Robles Home Care Services and staff from Doctor Steven Barr’s office. On 8/12/21 starting at 9:40 am interview was conducted with Licensee/Representative. Interview with Administrator revealed that R1’s responsible person did not want R1 to see any other physician besides Doctor Barr. Administrator stated that Doctor Barr was still R1’s physician. Interview with staff revealed that when Doctor Masongsong came to the facility in October 2020 they were using Inner Joy Health Home. Staff stated that they used to use Assisted Home Health and Los Robles Home Health.
Contined on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

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-NP-20210709071914

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: 02/06/2023

NARRATIVE

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Interview with R2’s family member stated that they were not made aware of any physical therapy order for R2 until they received a phone call from a nurse at Heart 2 Home Health stating that they saw R2 that day. Interview with Los Robles Home Care Services staff revealed that R1 was discharged from PT on 12/4/19. Interview with R1’s physician’s office revealed that they did not refer R1 for physical therapy in 2020. Interview with Licensee/Representative revealed that Dr. Masongsong is the doctor that goes to their facility to see their residents. Licensee/Representative stated that Dr. Masongsong refers residents to Innerjoy Home Health as well as other places. A review of R1’s records on 7/28/22 starting at 12:52 pm revealed that R1’s Health Insurance approved Physical Therapy for R1 on 2/18/19, 2/25/19 and 11/13/19 with Los Robles Home Care Services. On 11/10/2020 facility staff faxed R1’s physician requesting a doctor order for physical therapy. Facility received an order for physical therapy to evaluate and treat R1 on 11/10/2020. On 11/24/2020 R1’s responsible party received notification of denial of medical coverage from their Health Insurance which indicated that Inner Joy Home Health asked if they could have physical therapy services and they are a non-contracted provider. They denied the request and approved PT services with a contracted provider Los Robles Home Care Services. A review of R2’s records revealed that on 3/20/21 Dr. Masongsong ordered HH (Innerjoy) to evaluate R2 for physical therapy. Based on the information obtained during the investigation, the allegation that the facility did not inform responsible party regarding change in resident’s physical therapy is substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):

Exit interview conducted, reports and appeal rights were reviewed and printed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 29-NP-20210709071914

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: 02/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/13/2023 Section Cited HSC 1569.269(a)(20)	1 2 3 4 5 6 7	1569.269(a)(20) Enumerated rights; severability. To select their own physicians, pharmacies, privately paid personal assistants, hospice agency... in a manner that is consistent with the resident’s contract of admission or other rules of the facility, and in accordance with this act.	1 2 3 4 5 6 7	Administrator agreed to submit a statement of understanding of 1569.269(a)(20) to CCL by 2/13/2023
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as the licensee requested a change in Physical Therapist companies without prior notification to responsible parties which posed a potential personal	8 9 10 11 12 13 14	rights risk to persons in care.
	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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC9099 (FAS) - (06/04)

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