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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 10:21:22 AM


Document Has Been Signed on 09/22/2023 10:21 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
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Incident visit to the facility. 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 purpose of today's visit is to address a self reported Unusual Incident/Injury Report (LIC 624) reported to CCL on 09/19/2023.

The self reported Unusual Incident/Injury Report (LIC 624) pertains to an incident that occurred on 9/06/2023 regarding Residents #1 (R1), two staff (S1, S2), and a visitor. It was documented that on the evening of 9/6/2023 R1 did not want to be changed and S1 asked a visitor to hold R1, then S1 and S2 continued to to change R1 in front of the visitor, violating R1's personal rights. It was further reported that R1 had been combative due to not being provided their 1 p.m. and 5 p.m. medications by S1. S1 was terminated on 9/06/2023.


Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D).
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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Document Has Been Signed on 09/22/2023 10:21 AM - 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: VENTURA VILLA ASSISTED LIVING
FACILITY NUMBER: 565850093

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/29/2023
Section Cited
CCR
87468.1(a)(3)

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87468.1Personal Rights of Residents in All Facilities (a)(3)To be free from punishment, humiliation, intimidation, abuse, or other actions...interfering with daily living functions such as eating, sleeping, or elimination.This requirement is not met as evidence by:
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Office Manager Angelica Arambulo terminated S1 on the day of the incident, and S2 will be given a write up. Ofifice Manager agress to conduct an all staff trainning on personal rights and submit proof to CCL by POC due date.
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Based on Records obtained. The licensee did not comply with the above cited section as R1 was held down by a visitor and S1 and S2 changed R1 infront of the visitor which poses an immidiate personal rights risk to residents in care.
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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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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