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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850093
Report Date: 01/25/2024
Date Signed: 01/25/2024 06:12:01 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
01/03/2024 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20240103113700
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: 18DATE:
01/25/2024
UNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Angelica Arambulo-Office ManagerTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff are not properly trained to administer residents’ medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit for the above allegations. Upon arrival, LPA met with staff and was explained the reason for the visit. Office Manager Angelica arrived at the facilty at approximately 12:00 p.m.

On 1/09/2024, between 03:30 p.m. and 4:55 p.m., the LPA interviewed the Office Manager, staff, two residents, and obtained copies of resident records and other pertinent documents relevant to the investigation. During today's inspection, between 10:15 a.m. and 5:30 p.m., the LPA conducted a file review, interviewed the Office Manager, staff, residents, conducted a tour of the physical plant and obtained copies of resident records and other pertinent documents relevant to the investigation.

Report will contiue on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
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-AS-20240103113700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/25/2024
NARRATIVE
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It is alleged that the ‘Staff are not properly trained to administer residents’ medications. The concern of the RP is that employees are asked to give medicines to residents, but the employees are not certified to pass the medicine. To investigate the allegation LPA Cortez interviewed staff, the Office Manager, and conducted a file review. Staff interviews revealed that caregivers pass out medications to residents when there is no MedTech (MT) available. The Administrator stated that the caregivers who pass out medications to residents when the MedTechs are not available have been trained by one of the facilities MedTechs on how to pass the medication. However, there was no documentation on medication training available for the LPA to review for the caregivers that are passing out medications. On 1/09/24, during the initial 10-day complaint visit the Office Manager provided the LPA a certification of completion of 24 hours medication training program for four (4) MedTech’s at the facility. One out of the four MT’s no longer works at the facility. Furthermore, the certificates do not have any additional information other than the instructor’s signature. The Administrator stated that a pharmacist had come out to give the medication training, however could not provide additional information of the consultant such as the address, and telephone number of the consultant, the date when consultation was provided, the consultant’s organization affiliation, if any, and any educational and professional qualifications specific to medication management and, the training topics for which consultation was provided. Based on the information gathered through the interviews and documentation the allegation is Substantiated at this time.

During the visit Office Manager Angelica Arambulo left the facility and assigned MedTech Dora Islas to review and sign the report.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. . A copy of the report was issued, along with appeal rights.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
01/03/2024 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20240103113700

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: 18DATE:
01/25/2024
UNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Angelica Arambulo-Office ManagerTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Resident sustained unexplained bruising.
Facility is not supplying adequate food service.
Staff failed to provide a comfortable environment for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit for the above allegations. Upon arrival, LPA met with staff and was explained the reason for the visit. Office Manager Angelica Arambulo arrived at the facilty at approximately 12:00 p.m.

On 1/09/2024, between 03:30 p.m. and 4:55 p.m., the LPA interviewed the Administrator, staff, two residents, and obtained copies of resident records and other pertinent documents relevant to the investigation. During today's inspection, between 10:15 a.m. and 5:30 p.m., the LPA conducted a file review, interviewed the Administrator, staff, residents, conducted a tour of the physical plant and obtained copies of resident records and other pertinent documents relevant to the investigation.

Report will contiue on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
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-AS-20240103113700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/25/2024
NARRATIVE
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It is alleged that a ‘Resident sustained unexplained bruising’. The concern of the RP is that a resident sustained bruising and the RP does not think anyone reported this information. During this investigation LPA Cortez conducted interviews with Resident #1, facility staff, and a family member of the resident. In addition, R1’s medical records and facility records were reviewed. Information revealed that R1 had an un-witnessed fall in the room on 10/20/23, was taken to hospital for evaluation. Facility submitted an Unusual Incident/Injury Report (LIC624) to CCL on 10/22/23. R1 was diagnosed with a fall, contusions, facial hematoma, and dementia. The bruises could be from that fall. The general information also states the risk of falling is higher in older people, R1 ambulates most of the time. During LPA's interview with R1, it was learned that R1 is confused and cannot hold a conversation. There is no indication or evidence identified that R1 may have been physically abused. Interview with R1's family indicates that they are happy with the care being provided to R1 and have no concerns at this time. R1 is still residing at the same facility. Based on the information gathered through the interviews and file review there is insufficient evidence to support the above allegation. Therefore, although the allegation may have happened, or may be valid, this allegation is deemed Unsubstantiated at this time.

It is alleged that the ‘Facility is not supplying adequate food service’. The concern of the RP is that residents are not being provided snacks at night when asked for and are given hard bread. LPA Cortez interviewed residents, staff, and Office Manager, and conducted a tour of the kitchen. Interview with residents revealed that residents are being provided with snacks if requested. Residents stated that they also have snacks in their rooms. Interviews with facility staff revealed that snacks are available for residents such as fruit, yellow, and yogurt. Furthermore, staff stated that sandwiches and other items such as apple sauce are left in the staff refrigerator at night in case there’s residents that request food after the kitchen is closed. Interview with the Office Manager revealed that residents are provided with three meals a day, and two snacks, and additional snacks during activities. The administrator also stated that most residents don’t typically ask for food at night, however that staff is aware of what residents may be up at night wondering and have snacks available for them. During the tour of the kitchen, the LPA observed the refrigerator stocked with vegetables, fruit, yogurt, ice cream, milk, juice, and other foods. The freezer was stocked with frozen meats, and other frozen foods. Based on the information gathered through the interviews and observations there is insufficient evidence to support the claim that residents are not provided with adequate food service. Therefore, although the allegation may have happened, or may be valid, this allegation is deemed Unsubstantiated at this time. Report will continue on LIC9099-C...
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20240103113700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/25/2024
NARRATIVE
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It is alleged that the ‘Staff failed to provide a comfortable environment for residents’. The concern of the RP is that residents wear bibs to clean their faces, but when they do the laundry, they wash the bibs with the mop's rugs, and that residents are dressed in clothes not appropriate for the weather. Furthermore, it was alleged that resident #2 always gets cold water in the house. To investigate the allegation LPA Cortez interviewed residents, staff, and conducted a tour of the laundry room and R2’s room. Residents stated that they are treated well at the facility and have no concerns. Staff interviews revealed that bibs are not washed with the mop’s rugs and that residents are dressed in sweaters and jackets during the cold weather. The LPA observed residents wearing sweaters/jackets and observed some residents also with blankets. During the tour of the laundry room, the LPA observed bibs in the washing machine, however the LPA did not observe any mop’s rugs in the washing machine with bibs. Lastly, at 1:18 p.m. the LPA measured the hot water in R2’s restroom at 115.5 degrees Fahrenheit. Based on the information gathered through the interviews and observations there is insufficient evidence to support the above allegation. Therefore, although the allegation may have happened, or may be valid, this allegation is deemed Unsubstantiated at this time.

During the visit Office Manager Angelica Arambulo left the facility and assigned MedTech Dora Islas to review and sign the report. Exit interview conducted and report was issued.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20240103113700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/08/2024
Section Cited
HSC
1569.69
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§1569.69(a) (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training,...and 8 hours of other training or instruction,...
This requirement is not met as evidenced by:
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Administrator will provide a Statement of Understanding of the regulation 1569.69 and write a commitment/plan to ensure staff will not assist with medication management until they are fully trained. And provide the Pharmacist consultants information, who trained the MTs, to LPA by 2/08/24.
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Based on interviews, the licensee failed to comply with the section cited above as caregivers without complete medication training are passing medications, & training consultants inormation was not available which poses a potential health and safety risk to persons 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: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6