565850093-7-14-2021-29-AS-JROS-C4X4F4-20210714190317

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850093
Report Date: 07/14/2021
Date Signed: 07/14/2021 07:03:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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:	(818) 359-9447
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	49	CENSUS: 24	DATE:	07/14/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:19 PM
MET WITH:	Evangeline Ward-Michayluk		TIME COMPLETED:	06:36 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	Licensing Program Analyst (LPAs) JoAnn Rosales and KaSandra Lopez conducted an unannounced Case Management - Incident inspection at the facility due to receiving information of an incident during the investigation of complaint control #29-NP-20210709071914. At 12:19 pm LPA Rosales was conducting an interview with resident #1 (R1) regarding the complaint investigation. During the interview, R1 stated about a week and a half or two ago three or four males of which some were African American grabbed R1 out of bed and threw them to their bedroom floor. R1 stated that they wanted to report this to law enforcement. Upon receiving this information, LPA Rosales notified the Administrator and requested that they call law enforcement. The LPA also requested the Administrator to complete an Incident Report and the Report of Suspected Dependent Elder Abuse form (SOC341) and cross report. At approximately 1:00 pm a review of R1's file was conducted and pertinent copies of records were obtained. During the inspection Law enforcement came to the facility and interviewed R1. At 2:07 pm the LPAs met with two law enforcement officers who stated that after interviewing R1 they would not be conducting any further investigation. LPA Rosales obtained the police report number from the investigation. Interviews with the Administrator revealed that they were not aware of this alleged incident reported by R1. The Administrator also stated that there is only one male staff working at the facility during the night shift and there are no African American staff or residents residing in the facility. At 2:27 pm the LPAs attempted to interview R2 who is the roommate of R1. Due to their medical condition, the LPAs were unable to conduct an interview with R2. At 2:31 pm the LPAs conducted an interview with R3 who resides in the room next to R1. R3 reported no issues or concerns of unwanted individuals coming into Continued on 809C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VENTURA VILLA ASSISTED LIVING	FACILITY NUMBER: 565850093
	VISIT DATE: 07/14/2021

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their room or any reports of being abused. At 2:43 pm an interview conducted with R4 revealed no issues or no unwanted individuals coming into their room or any reports of being abused. At 2:53 pm an interview with R5 revealed no issues of concerns regarding how they are being treated at the facility. At 4:17 pm LPA Rosales conducted a telephone interview with staff #1 (S1) who works the overnight shift. S1 denied ever pulling any residents out of bed and throwing them on the ground. S1 stated that they are the only male staff who works at night. S1 reported no incidents of outside individuals coming into the facility and assaulting any residents.

The facility is approved for delayed egress and secured perimeter of which individuals cannot enter the building or exit the building without staff unlocking the doors and granting entry/exiting. Based on the information obtained during the investigation there is insufficient evidence at this time to support R1 was physically abused at the facility.

Exit interview was conducted, today's report was reviewed and emailed to the Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

LIC809 (FAS) - (06/04)

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