<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850093
Report Date: 07/14/2021
Date Signed: 07/14/2021 07:07:14 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
07/09/2021 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-NP-20210709071914
FACILITY NAME:VENTURA VILLA ASSISTED LIVINGFACILITY NUMBER:
565850093
ADMINISTRATOR:WARD-MICHAYLUK, EVANGELINEFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA ROADTELEPHONE:
(818) 359-9447
CITY:VENTURASTATE: ZIP CODE:
93003
CAPACITY:49CENSUS: 24DATE:
07/14/2021
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Evangeline Ward-MichaylukTIME COMPLETED:
06:36 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's personal rights were violated
Resident was transported in an unsafe manner and/or vehicle
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
During today's visit Licensing Program Analysts (LPA's) JoAnn Rosales and KaSandra Lopez toured the facility with Administrator, reviewed random resident records, interviewed random staff and obtained copies of pertinent documents.

Concerns were that resident #1 (R1)'s rights were violated as housekeeping staff threw away R1's AARP bulletins. Interview with staff (S1) starting at 10:53 am revealed that S2 removed R1's AARP magazines from their room and placed them on their housekeeping cart to throw out. Interview with S2 starting at 11:44 am revealed that they removed a newspaper and magazines from R1's room as they thought that R1 did not need them anymore and placed them on their housekeeping cart. Concerns were that R1 was transported in an unsafe manner and/or vehicle as R1 was transported in S1's personal vehicle for an appointment. Interview with Administrator at 5:12 pm revealed that they did not do a car safety inspection and only confirmed verbally that S1 had current car insurance prior to S1 transporting R1 to their appointment.
Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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 6
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: 07/14/2021
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
26
27
28
29
30
31
32
Interview with S1 revealed that they transported R1 in their personal vehicle to an appointment. S1 stated that the Administrator did not request a copy of their current automobile insurance information and they were not required to do any safety checks on the vehicle prior to transporting R1 to their appointment. Starting at 11:35 am LPA's observed S1's vehicle with working blinkers, hazards, brake lights, horn and headlights. LPA's observed a crack on the passenger side windshield. S1 stated that the crack on the windshield happened on 7/10/21. LPA's observed current automobile insurance information for S1's vehicle. Based on the information obtained during the course of the investigation the allegations are deemed substantiated at this time.

Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/23/2021
Section Cited
CCR
1569.269(a)(30)
1
2
3
4
5
6
7
1569.269 Enumerated rights; severability (a)(30) To keep, have access to, and use their own personal possessions, including toilet articles, and to keep and be allowed to spend their own money, unless limited by statute or regulation.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator stated that they will provide documentation of staff training regarding residents rights to CCL by 7/23/21.
8
9
10
11
12
13
14
Based on interviews, the licensee did not comply with the section cited above as staff removed R1’s personal items from their room which poses a potential personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
07/23/2021
Section Cited
CCR
87312
1
2
3
4
5
6
7
87312 Motor Vehicles Used in Transporting Residents. Only drivers licensed for the type of vehicle operated shall be permitted to transport residents. The rated seating capacity... Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator stated that they will no longer being using staff to transport residents in their private vehicles as they have a contract with a medical transport company.
8
9
10
11
12
13
14
Based on interviews, the licensee did not comply with the section cited above as licensee did not verify that S1's vehicle was maintained in a safe operating condition prior to transporting R1 which posed a potential safety and personal rights risk to persons in care.
8
9
10
11
12
13
14
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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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 Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-NP-20210709071914

FACILITY NAME:VENTURA VILLA ASSISTED LIVINGFACILITY NUMBER:
565850093
ADMINISTRATOR:WARD-MICHAYLUK, EVANGELINEFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA ROADTELEPHONE:
(818) 359-9447
CITY:VENTURASTATE: ZIP CODE:
93003
CAPACITY:49CENSUS: 24DATE:
07/14/2021
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Evangeline Ward-MichaylukTIME COMPLETED:
06:36 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee did not provide responsible party sufficient notice for rate increase
Resident was denied access to bathroom
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
During today's visit Licensing Program Analysts (LPA's) JoAnn Rosales and KaSandra Lopez toured the facility with Administrator, reviewed random resident records, interviewed Administrator and obtained copies of pertinent documents.

Concerns were that the Licensee did not provide R1's responsible party with sufficient notice for a rate increase. Interview with Administrator starting at 1:41 pm revealed that they were not working at Treacy Villa when R1 was sent a rate increase letter in May 2020. At 2:16 pm LPA's observed an email dated 5/14/2020 with an attached letter dated 5/12/2020 sent to R1's responsible person regarding a rate increase efffective 1/1/21. Concerns were that R1 was denied access to their bathroom as their bathroom door was locked for one week. Interview with licensee/representative starting at 4:50 pm revealed that they received a phone call from R1's responsible party on 4/16/21 indicating that R1's bathroom door was locked by another resident and R1 had to call a caregiver to unlock the bathroom door. Licensee/representative stated that they removed the
Continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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: 07/14/2021
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
26
27
28
29
30
31
32
lock from R1's bathroom door however, R1's responsible person stated that R1 would not have privacy so Licensee/representative placed the lock back on the bathroom door. Licensee/representative stated that the lock is a toggle lock and can be locked and unlocked from both sides of the door. During Interview with R1 at 12:19 pm R1 pointed out the lock on their bathroom door indicating that the door was locked. LPA's observed R1's bathroom door to be unlocked. R1 stated that sometimes the door is locked sometimes it is not locked. Interview with S2 and S3 starting at 11:56 am revealed that they were unaware of R1's bathroom door being locked and R1 not having access to the bathroom. Based on the information obtained during the course of the investigation the allegations are deemed unsubstantiated at this time.

Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6