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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850141
Report Date: 07/23/2024
Date Signed: 07/23/2024 04:25:29 PM

Document Has Been Signed on 07/23/2024 04:25 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/
DIRECTOR:		LANCE SHENKFACILITY TYPE:
740
ADDRESS:4964 TELEGRAPH ROADTELEPHONE:
(805) 650-1114
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 100CENSUS: 79DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:09 AM
MET WITH:Jeanphilippe RolletTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Angela Barutyan and Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 10:09AM. LPAs met with Health Services Director (HSD) Aleesha Zuniga, and Administrator Jeanphilippe Rollet. Entrance interview conducted.

At 10:41AM, LPAs began file review while Administrator finished up a tour of the facility.
At 01:12PM, the LPAs conducted a tour of the physical plant with Administrator Rollet to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

The following was noted: Facility is a double-story residence that consists of 2 (two) memory care units named Creekside and Oceanside respectively, and an assisted living (AL) unit. The LPAs observed fire extinguishers throughout the facility, which were fully charged and last serviced 06/05/2024. The Administrator provided an annual fire alarm testing and inspection report done on 04/04/2024 where all smoke alarms and carbon monoxide detectors were tested and functioned properly. At 1:22PM, LPAs tested 1 (one) delayed egress door in the Creekside unit and was observed to be functional. The LPAs observed all required postings in the hallway near the entrance area. The facility serves residents with dementia, and the auditory alarms on the exit doors were tested and functioned properly at the time of visit.

KITCHEN: At 1:25PM, LPAs toured the kitchen. Kitchen was observed to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of 7 (seven) days non-perishable and 2 (two) days perishable food. LPAs observed dietary restrictions and accommodations for residents posted throughout the kitchen. Food is prepared based on the menu. Snacks and beverages are available for residents at the bistro.
Report Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 VENTURA
FACILITY NUMBER: 565850141
VISIT DATE: 07/23/2024
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BEDROOMS: During today’s visit, the LPAs observed 10 (ten) resident rooms of which 3 (three) were in the Creekside unit, 3 (three) were in the Oceanside unit, and 4 (four) were in the AL unit. The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

BATHROOMS: The LPAs observed 10 (ten) resident bathrooms which were properly supplied and had functional fixtures at the time of the visit. The LPAs observed grab bars by the toilet/shower and non-skid surfaces in all bathrooms. Between 1:20PM and 2:32PM, water temperatures in all 10 (ten) bathrooms were measured between 107.5 and 116.7 degrees Fahrenheit, which is within the required range.

COMMON AREAS: These included the beauty salon, library, bistro and dining areas in assisted living and memory care units. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature of 71 degrees. There were no obstructions and/or tripping hazards throughout the facility.



GROUNDS/OUTDOORS: The LPAs observed appropriate outdoor furniture, with covered shaded areas for residents in both memory care units’ courtyards and the assisted living courtyard. Parking is available for residents and visitors. The LPAs observed a water fountain with an appropriate amount of water that does not pose a risk for residents.

INFECTION CONTROL: The community's policies and procedures pertaining to infection control are adequate.

RECORD REVIEW: LPAs began record review at 10:41AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. LPA Byrne reviewed 5 (five) of 79 (seventy-nine) resident files and were observed to contain all required documents. LPA Barutyan reviewed 5 (five) staff files and were observed to contain all required documents.

Report Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 VENTURA
FACILITY NUMBER: 565850141
VISIT DATE: 07/23/2024
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MEDICATION REVIEW: Medications for 5 (five) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

INTERVIEWS: During today’s visit, the LPAs conducted 5 (five) resident interviews and five (5) staff interviews. No concerns voiced during the interviews.

During today's visit, LPAs obtained a copy of the facility's liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Civil penalty was issued in the amount of $500. Administrator was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted and copy of the report and appeal rights provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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Document is an Amendment of Original Document on 06/05/2025 02:07 PM


Created By: Kelly Burley On 07/23/2024 at 04:06 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AEGIS LIVING VENTURA
FACILITY NUMBER: 565850141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

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 that 1 (one) staff member did not have a transfer of criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Administrator agrees to have staff member associated to the facility by the plan of correction 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:Jill Nakata
LICENSING EVALUATOR NAME:Kelly Burley
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


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