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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850093
Report Date: 04/12/2022
Date Signed: 04/18/2022 11:09:38 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/26/2021 and conducted by Evaluator Teresa Camara
PUBLIC
COMPLAINT CONTROL NUMBER: 29-NP-20210826165010
FACILITY NAME:VENTURA VILLA ASSISTED LIVINGFACILITY NUMBER:
565850093
ADMINISTRATOR:WARD-MICHAYLUK, EVANGELINEFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA ROADTELEPHONE:
(805) 644-1292
CITY:VENTURASTATE: ZIP CODE:
93003
CAPACITY:49CENSUS: 19DATE:
04/12/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Evangaline "Joy" Ward-MichaylukTIME COMPLETED:
05:36 PM
ALLEGATION(S):
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Facility failed to provide or assist with arranging timely medical transportation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings on the above noted allegation. LPA met with administrator Joy Ward-Michayluk and explained the reason for the visit.

LPA Camara had visited the facility on 09/03/2021 and conducted a plant tour at 10:25 a.m., reviewed records at 11:15 a.m., and interviewed Staff 1 (S1) at 12:40 p.m. and Staff 2 (S2) at 2:50 p.m. Resident 1 (R1) experienced severe abdominal pain on 08/26/2021. Staff called R1's doctor who asked for R1 to be sent to the hospital emergency room. Staff called R1's family who requested staff find free transportation for R1 rather than call 9-1-1. Staff indicated this was an emergency and there was not time to look for free transportation. After some back and forth with the family, staff called 9-1-1 to take R1 to the emergency room. Based on the records reviewed and staff interviews, this allegation is Unsubstantiated at this time. Exit interview conducted and a copy of the report was emailed to the administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/26/2021 and conducted by Evaluator Teresa Camara
PUBLIC
COMPLAINT CONTROL NUMBER: 29-NP-20210826165010

FACILITY NAME:VENTURA VILLA ASSISTED LIVINGFACILITY NUMBER:
565850093
ADMINISTRATOR:WARD-MICHAYLUK, EVANGELINEFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA ROADTELEPHONE:
(805) 644-1292
CITY:VENTURASTATE: ZIP CODE:
93003
CAPACITY:49CENSUS: 19DATE:
04/12/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Evangaline "Joy" Ward-MichaylukTIME COMPLETED:
05:36 PM
ALLEGATION(S):
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Facility failed to provide supplies necessary for personal care and maintenance of adequate hygiene
Facility failed to provide individual privacy in resident bathroom
Facility failed to provide safe, comfortable accomodations
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings on the above noted allegation. LPA met with administrator Joy Ward-Michayluk and explained the reason for the visit.

LPA Camara had visited the facility on 09/03/2021 and conducted a plant tour at 10:25 a.m., reviewed records at 11:15 a.m., and interviewed Staff 1 (S1) at 12:40 p.m. and Staff 2 (S2) at 2:50 p.m. LPA observed several resident bathrooms lacking toilet paper and paper towels. LPA also observed resident bathrooms which lack locks on the doors and prevent resident from privacy as other residents in adjoinnig rooms have access to the same "Jack and Jill" style bathroom. Therefore, the above allegations are deemed Substantiated at this time.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted, report issued, and appeal rights provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-NP-20210826165010
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2022
Section Cited
CCR
87303(c)
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87303(c) Personal Accommodations and Services. Individual privacy shall be provided in all toilet, bath and shower areas.

This requirement is not met as evidenced by:
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Administrator has already ensured that all bathrooms have locks. This was completed in September of 2021.
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LPA observed several resident bathrooms that lacked locks on bathroom doors. These are "Jack and Jill" style bathrooms where adjoining rooms use the same bathroom and can enter when someone else is using the bathroom, which poses a potential health and safety risk to residents in care.
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Type B
04/25/2022
Section Cited
CCR
87303(a)(3)(D)
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87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and
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Administrator will provide training to staff to ensure resident bathrooms have adequate supply of personal hygiene items, including toilet paper and paper towels. Supplies will be limited to smaller amounts due to several residents clogging plumbing with excess paper supplies. Evidence of training will be provided to CCL by 4/19/22.
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supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (D) Hygiene items of general use such as soap and
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toilet paper. This requirement was not met as evidenced by:
LPA observed resident bathrooms which lacked toilet paper and paper towels, which is a potential health and safety risk to residents in care.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3