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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850093
Report Date: 06/22/2022
Date Signed: 06/22/2022 01:17:26 PM


Document Has Been Signed on 06/22/2022 01:17 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,
, CA



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: 17DATE:
06/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Evangeline (Joy) MichaylukTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a required annual visit, which has an emphasis on infection control practices and procedures. The LPA met with Licensee Evangeline (Joy) Michayluk and informed them of the reason for the visit.

At 09:20AM, the LPA and Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations.

Common Areas: There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature throughout the building. There are fire extinguishers throughout the facility, which were fully charged and last serviced 11/16/2021. The LPA observed staff engaging residents in group activities. All common spaces appeared clean and in good repair.

At 09:21AM, the Storage closet, which contains Shampoo & Body Wash, Peri-Rinse, and other personal care items was observed to be unlocked and accessible to residents in care. At 09:42AM, the Linen Closet containing Shampoo & Body Wash, Peri-Rinse, Jergens body lotion, Dove Body Wash, incontinence care cart, and other personal care items was observed to be unlocked and accessible to residents in care.

Kitchen: The facility had a sufficient supply of two-day perishable and seven-day nonperishable food at the time of the visit. Food is prepared based on the menu and modified as needed for individual residents. Administrator stated a large monthly food order will be delivered Monday and perishable foods are purchased as needed throughout the month. Snacks and beverages are available for residents at all times.

Outside areas: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Parking is available for residents and visitors.

Resident Rooms: The facility is a one story building. Resident rooms can be designated for either single or double occupancy. All resident rooms have either a private restroom or a "jack and jill" restroom shared with Report Continued on LIC 809-C

SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
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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Document Has Been Signed on 06/22/2022 01:17 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,
, CA


FACILITY NAME: VENTURA VILLA ASSISTED LIVING
FACILITY NUMBER: 565850093

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 of 2 resident bathrooms water temperature was observed to be 99.8 degrees Fahrenheit and 102.5 degrees Fahrenheit which poses an immediate health risk to persons in care.
POC Due Date: 06/23/2022
Plan of Correction
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Hot water heater was replaced yesterday; the technician who conducted the installation yesterday is who will need to adjust the temperature. Licensee contacted the technician during today's visit. Technician will return to the facility to adjust the temperature at 10:00AM on 06/23/2022. Licensee will check and record temperatures daily for 7 days and submit the record to CCL by 07/01/2022.
Type A
Section Cited
CCR
87705(g)
Care of Persons with Dementia
(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as both the linen closet containing shampoo & body wash, peri-rinse, Jergens lotion and a supply closet containing personal care items were left unlocked and 1 of 3 residents' records reviewed indicated they are "at risk if allowed direct access to personal grooming and hygiene items" which poses an immediate safety risk to persons in care.
POC Due Date: 06/22/2022
Plan of Correction
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Both closets were locked during today's visit. Licensee will conduct a training with all staff on section 87468(a)(12) and submit proof of training, including name of trainer, date of training, and all attendees to CCL by 07/01/2022.

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: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/22/2022 01:17 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,
, CA


FACILITY NAME: VENTURA VILLA ASSISTED LIVING
FACILITY NUMBER: 565850093

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one of 3 records reviewed, the resident has a diagnosis of dementia and the last physician's report was incomplete and dated 04/07/2021 which poses a potential health risk to persons in care.
POC Due Date: 07/06/2022
Plan of Correction
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Administrator agreed to obtain a new complete physican's report for Resident #1 (R1) and submit proof to CCL by 07/06/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022
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,
, CA
FACILITY NAME: VENTURA VILLA ASSISTED LIVING
FACILITY NUMBER: 565850093
VISIT DATE: 06/22/2022
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the adjoining room.

At 09:35AM, water temperature in room #105's restroom was measured at 99.8 degrees Fahrenheit. At 09:40AM, water temperature in the"jack and jill" restroom between rooms #103 and #101 was measured at 102.5 degrees Fahrenheit. Administrator indicated the water heater was replaced yesterday and had been set to 120 degrees Fahrenheit.

Record Review: At 11:26AM, LPA reviewed records for three (3) residents for documents including but not limited to Physican's Report and Appraisal Needs and Service Plan. One (1) of three (3) residents, who has a diagnosis of Dementia, had a physician's report dated 04/07/2021.

Infection Control: Prior to entry to the facility, there is a central entry point for symptom screening and temperature checks for staff, and visitors. Staff and visitors were observed wearing appropriate face coverings throughout the visit. During today’s visit, the LPA spoke with the Administrator regarding the community's infection control practices. The community has an adequate supply of Personal Protection Equipment (PPE) and is able to obtain additional supplies. The community's cleaning protocol is sufficient. This facility has records of staff and resident vaccinations. If needed, the facility has the capacity to designate isolation rooms if there is a confirmed case of COVID-19, as well as a COVID-19 wing. The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The community's policies and procedures pertaining to infection control were adequate.


Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, todays reports, and appeal rights were reviewed and emailed to the Licensee.
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC809 (FAS) - (06/04)
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