565850093-6-15-2023-29-AS-ECOZ-CSU3AZ-20230615180535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850093
Report Date: 06/15/2023
Date Signed: 06/15/2023 06:07:51 PM

Document Has Been Signed on 06/15/2023 06:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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:	(805) 644-1292
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	49	CENSUS: 17	DATE:	06/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Evangeline Ward-Michayluk		TIME COMPLETED:	06:15 PM

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	At 10:20 a.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Administrative Assistant Erendira Guadarrama and informed them of the reason for the visit. Office Manger Angelica Arambulo arrived shortly. At 10:40 a.m. the LPA conducted a tour of the physical plant with Administrative Assistant Guadarrama and Office Manager Arambulo to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of twenty-five (25) resident bedrooms (thirteen (13) being occupied by residents), one (1) staff room, sixteen (16) bathrooms and four (4) shower rooms. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 11/14/2022. All smoke alarms and carbon monoxide detectors were tested and functioned properly during time of visit. LPA observed all required postings in the entrance area. Kitchen: During the facility tour, at 10:46 a.m. the LPA observed the kitchen to be kept inaccessible to the residents. The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. The LPA observed food containers not properly labeled with no expiration dates in the kitchen. At 11:05 a.m. the LPA observed the following expired food in the pantry: - One (1) Sesame Oil with the expiration date of 07/23/2022 - One (1) Pad Thai Sauce with the expiration date of 7/31/2022 - One (1) box of Stevia Sweetener with the expiration date of 12/01/2022 - One (1) Powdered Pure Cane Sugar bag with the expiration date of 11/2022 - One (1) Distilled White Vinegar bottle wit the expiration date of 7/24/2022 Report will continue on LIC809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VENTURA VILLA ASSISTED LIVING	FACILITY NUMBER: 565850093
	VISIT DATE: 06/15/2023

NARRATIVE

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The Administrative Assistant stated they will discard all expired food today and properly label all food containers with expiration dates. There was a sufficient supply of cooking and dining ware. There were no visible immediate hazards observed.

Bedrooms: The resident bedrooms were properly furnished with at least one chair, night-stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 11:45 a.m. the LPA observed room #406 (not bedridden cleared) who was documented to have a bedridden resident on the resident roster. After observation the administrative assistant stated that resident #1 (R1) was not bedridden and resident roster had not been updated. The LPA verified with R1'S Physician report to not be bedridden but non-ambulatory.
Bathrooms: At 11:36 a.m., the LPA observed the bathroom between rooms #101 and #103, with no trash can lid. At 11:41 a.m., the LPA observed the restroom between rooms #406 and #408 with a broken cabinet door in the bottom right of the sink. At 11:44 a.m., the LPA observed the bathroom between rooms #409 and #411, with no trash can lid, a toilet plunger over the sink, a walker next to the toilet and a wheelchair in front of the sink. At 12:08 p.m., the LPA observed the bathroom between rooms #402 and #404 with no trash can available. The office manager designated a staff personnel to clear the restrooms of any items and showed the LPA the new trash can with lid they had purchased for residents bathrooms. The LPA observed grab bars and non-skid tiles in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. At 12:05 p.m., water temperature in the bathroom between rooms #302 and #304 was measured at 97.2 degrees Fahrenheit. At 12:16 p.m., water temperature in room #105's restroom was measured at 99.2 degrees Fahrenheit. The water measured was not within the required limit of 105-120 degrees Fahrenheit. Office Manager delegated staff to adjust the hot water upon observation.

Common Areas: These included the, hallways, living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a television, piano, puzzles and other indoor activities available for resident use. The facility maintained a comfortable temperature of 71 degrees. At 11:16 a.m., the LPA observed a rolling cart being used as a door stopper and blocking the door exit next to the kitchen leading to the outside patio. Administrative Assistant removed the rolling cart upon observation and LPA discussed safety hazards with them. They later found out that a resident had placed the cart at the door. Report will continue on LIC809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VENTURA VILLA ASSISTED LIVING	FACILITY NUMBER: 565850093
	VISIT DATE: 06/15/2023

NARRATIVE

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At 11:28 a.m., the LPA observed a wooden rolling physical activity cart more than 5 feet in height blocking the exit door between rooms #209 and #207. Office Manager delegated staff to move the wooden cart to another location upon observation. LPA discussed safety hazards with the Administrative Assistant.

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Parking is available for residents and visitors. There are no bodies of water on the premises.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Due to time constraints the LPA will return to complete the annual at a later date.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 06/15/2023 06:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VENTURA VILLA ASSISTED LIVING	FACILITY NUMBER: 565850093
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as five (5) food items in the food pantry were expired which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/16/2023
	Plan of Correction
1 2 3 4	Licensee agrees to complete a food audit to ensure all food is of good quality, discard all expired food items and labeled all containers with an experation date. Complete audit by the end of day on 6/16/2023 and informed CCL when audit is complete not later than the POC due date.

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in two (2) of two (2) resident bathrooms water temperature was observed to be 97.2 degrees and 99.1 Fahrenheit which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/16/2023
	Plan of Correction
1 2 3 4	Office Manager delegated staff to adjust the hot water in the residents rooms. Licensee will check and record temperatures daily for 7 days and submit the record to CCL by 06/26/2023.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

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