<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850093
Report Date: 09/03/2021
Date Signed: 09/03/2021 03:34:33 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 LIVINGFACILITY NUMBER:
565850093
ADMINISTRATOR:WARD-MICHAYLUK, EVANGELINEFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA ROADTELEPHONE:
(805) 644-1292
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:49CENSUS: 20DATE:
09/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Evangeline "Joy" Ward-MichaylukTIME COMPLETED:
03:35 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 Analysts (LPAs) Teresa Camara and Kelly Dulek conducted an unannounced case management inspection due to a death report submitted to the Regional Office on 08/31/2021. LPAs met with Assistant Administrator Jennifer Sharma and explained the reason for the visit. Administrator Evangeline "Joy" Ward-Michayluk arrived at 11:15AM.

The reason for today's inspection was to follow up on the death report for resident #1 (R1) received in the Regional Office on 08/31/2021. During today's inspection, the LPAs toured the facility at 10:28AM, conducted staff interviews between 11:40AM and 2:50PM, reviewed resident records at 11:20AM, and gathered copies of pertinent documents. At this time further investigation is needed.

A exit interview was conducted with Evangeline "Joy" Ward-Michayluk, and a hard copy was provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
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 1