565850093-6-5-2024-29-AS-KDUK-D5XUZW-20240605160214

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850093
Report Date: 06/05/2024
Date Signed: 06/05/2024 04:02:23 PM

Document Has Been Signed on 06/05/2024 04:02 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
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:	(805) 644-1292
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	49	CENSUS: 21	DATE:	06/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Angelica Arambulo		TIME COMPLETED:	04:05 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 (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit. Upon arrival, LPA met with Operations Manager Angelica Arambulo. Entrance interview conducted.

At 01:27PM, the LPA, along with facility staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

RECORD REVIEW: LPA reviewed staff and resident files for documents including, but not limited to: physician's report, Admission Agreements, personal rights, staff fingerprint background clearance, TB test results and health screenings. 1 (one) staff (Staff #1 - S1) did not have proof of fingerprint background clearance, but has been working for the facility since April 2024. Additional items observed will be addressed during the annual continuation visit.

RESIDENT ROOMS/RESTROOMS: Resident rooms are either single or double occupancy. 10 (ten) resident rooms were observed during today's visit and contained the appropriate furnishings, linens, and bedding. Resident restrooms are jack-and-jill style - shared between 2 adjacent rooms. Restrooms observed were clean and sanitary in operating condition. Water temperature was tested in a sample of resident restrooms and measured at 86.4 degrees Fahrenheit in one resident restroom. Other remaining resident water temperatures were within the required range.

COMMON AREAS: Laundry room door lock and staff room door lock were observed to both be broken at the time of the visit. Laundry detergent was observed to be accessible in the laundry room and staff belongings, which included visible medications, among other personal belongings were also accessible to residents in care.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

Document Has Been Signed on 06/05/2024 04:02 PM - 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VENTURA VILLA ASSISTED LIVING	FACILITY NUMBER: 565850093
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.17(c)(1)(A)

Licensing

(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as 1 (one) out of 4 (four) staff whose records were reviewed did not have criminal record clearance, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/06/2024
	Plan of Correction
1 2 3 4	Operations Manager is aware Staff #1 cannot work until criminal background clearance is received. Proof of modified staff schedule will be provided to CCL by POC due date and criminal record clearance will be provided to CCL upon receipt.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 06/05/2024 04:02 PM - 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VENTURA VILLA ASSISTED LIVING	FACILITY NUMBER: 565850093
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as both laundry room and staff room door locks were observed to be broken and unusable; laundry room contained accessible laundry detergent, staff room contained accessible staff personal belongings, including a visible medication bottle, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/19/2024
	Plan of Correction
1 2 3 4	Items were secured during today's visit. Facility staff indicated the door locks are scheduled to be repaired. Proof of repair will be sent to CCL by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 06/05/2024

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
26
27
28
29
30
31
32

BUILDINGS AND GROUNDS: During facility tour, LPA noted that all exterior gates are padlocked and/or chained and locked. Facility staff stated that the cameras were being repaired and in the meantime, gates were locked for resident safety. Operations Manager stated that if the gates are locked, this should be approved in the fire clearance. Review of facility plan of operation and fire clearance documents are unclear whether locked perimeter is approved. Further investigation is needed to determine if a violation occurred. LPA will address this during the annual continuation visit.

Due to time constraints, LPA will return at a later date to continue the annual inspection.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. A $500 civil penalty was assessed. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of today's report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4