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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850093
Report Date: 08/17/2023
Date Signed: 08/17/2023 05:31:53 PM


Document Has Been Signed on 08/17/2023 05:31 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 LIVINGFACILITY NUMBER:
565850093
ADMINISTRATOR:WARD-MICHAYLUK, EVANGELINEFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA ROADTELEPHONE:
(805) 644-1292
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:49CENSUS: 16DATE:
08/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Angelica Arambula TIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Incident inspection pertaining to a self reported Unusual Incident/Injury Report (LIC 624) received on 08/17/2023. The LPA was greeted by Med Tech Dora Islas and informed them of the reason for the visit. Office Manger Angelica Arambulo arrived shortly.

The self reported Unusual Incident/Injury Report (LIC 624) pertains to an incident that occurred approximately the weekend of 8/07/2023 regarding Residents #1,2 and 3 (R1, R2, R3). During today's inspection, the LPA conducted interviews with two staff and four residents (R1, R2, R3, R4). The LPA interviewed the Office Manager Angelica Arambula throughout the visit. At 10:45 a.m. the LPA reviewed facility records and obtained copies of pertinent records.

No immediate health and safety concerns were observed during today's inspection. The LPA has determined further investigation is needed. The report was issued to Office Manager Angelica Arambula.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
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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