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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850141
Report Date: 01/16/2024
Date Signed: 01/16/2024 04:55:13 PM

Document Has Been Signed on 01/16/2024 04:55 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AEGIS LIVING VENTURAFACILITY NUMBER:
565850141
ADMINISTRATOR:LANCE SHENKFACILITY TYPE:
740
ADDRESS:4964 TELEGRAPH ROADTELEPHONE:
(805) 650-1114
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 100CENSUS: 84DATE:
01/16/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Lance ShenkTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 07/11/2023. The LPA was greeted by Business Office Manager Hannah Robertson and informed them of the reason for the visit. Administrator Lance Shenk arrived during the visit.

Today the LPA conducted a medication audit and finished the record review initiated on 7/11/2023.

Record Review: The LPA observed documentation of Disaster prevention and last fire drill (conducted on 12/12/2023).

Medications: At 2:30 p.m. a medication review was initiated for two out of five residents and the following was observed. The medications were stored in Med carts, which are locked and inaccessible to the residents. During Resident #1 (R#1's) audit, the LPA observed the expiration date for fifteen (15) medications not properly documented as they did do not match the Facility Centrally Stored Medication and Destruction Record (CSMDR). During R#2’s audit, there were two medications that were not documented on the centrally stored log. Staff stated the CSMDR for those medications were stored in a different location due to the date they were filled. The LPA also observed the expiration date for nine (9) medications of R2 not properly documented as they did not match the CSMDR. R2’s date started for Vitamin D2 1.25mg and Lorazepam 1mg were not properly documented, as R2 has not started the medication and a start date was documented. Staff documented the correct expiration dates and corrected the start dates upon observation.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024
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 2
Document Has Been Signed on 01/16/2024 04:55 PM - It Cannot Be Edited


Created By: Esther Cortez On 01/16/2024 at 04:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AEGIS LIVING VENTURA
FACILITY NUMBER: 565850141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

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 two out of five resident medication audits which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2024
Plan of Correction
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Licensee agrees to complete a letter of understanding of regulation 87465 and submit to CCL by POC due date.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024


LIC809 (FAS) - (06/04)
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