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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850093
Report Date: 09/22/2023
Date Signed: 09/22/2023 10:23:50 AM


Document Has Been Signed on 09/22/2023 10:23 AM - 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 N.ASC, 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: 17DATE:
09/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Catalina Gonzales-StaffTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced subsequent Case Management - Incident visit to the above facility. The purpose of the visit is to conclude an investigation initiated by LPA during a Case Management- Incident visit conducted on 08/17/2023. The LPA was greeted by Staff Catalina Gonzalez and informed them of the reason for the visit. Office Manger Angelica Arambulo was unable to be at the facility during today’s visit and authorized Catalina Gonzales to sign and receive the report.

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). On 8/17/2023, 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.

It was reported that staff (S1, S2) was witnessed hitting R1, R2, R3. On 8/17/2023 Office Manager Angelica Arambula stated that both staff had been suspended.


Although a violation of Title 22 of the CA Code of Regulations was noted, the deficiency was cited on a separate report from a case-management visit on 9/22/2023. Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
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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