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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850141
Report Date: 06/13/2022
Date Signed: 06/13/2022 03:34:19 PM


Document Has Been Signed on 06/13/2022 03:34 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:AEGIS LIVING VENTURAFACILITY NUMBER:
565850141
ADMINISTRATOR:KAREN G GOROYANFACILITY TYPE:
740
ADDRESS:4964 TELEGRAPH ROADTELEPHONE:
(805) 650-1114
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:100CENSUS: 75DATE:
06/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Karen Gary GoroyanTIME COMPLETED:
02:37 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Required -1 Year inspection. LPA met with Administrator Karen Gary Goroyan.

During facility tour to inspect for infection control practices LPA observed one central entry point designated for universal entry screening. Cleaning supplies were observed and infection control practices were discussed. An inspection of the common area, resident rooms and restrooms were conducted hot water temperature (read at 114.8, 107.9, 104.7 and 111.6 degrees F.) in resident bathrooms. Grab bars were present in the bathrooms. Hygiene items are being provided. LPA observed a sufficient supply of perishable and nonperishable food. LPA observed appropriate lighting in the facility. LPA observed the fire extinguishers fully charged. The smoke alarms and carbon monoxide detectors were tested and were operable. Disinfectants and cleaning supplies were in a locked janitors and housekeeping room. Medications were centrally stored and are kept in locked medication carts and medication room. First Aid kit is complete. LPA observed a sufficient supply of PPE. Outdoor area toured- passageways are free of obstruction.

During facility tour with the Administrator at 10:48 am LPA observed an unlocked medication cart in the Creekside memory care activity room accessible to residents.

During facility tour with the Administrator and staff Mark Brassfield at 11:14 am LPA observed scissors in an unlocked activities directors office accessible to residents.

During facility tour with the Administrator and staff Brassfield at 11:28 am LPA observed after shave balm and aveeno daily moisturizer in an unlocked drawer in Oceanside memory care accessible to residents.

Continued on 809C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
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 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AEGIS LIVING VENTURA
FACILITY NUMBER: 565850141
VISIT DATE: 06/13/2022
NARRATIVE
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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 appeals rights were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/13/2022 03:34 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: AEGIS LIVING VENTURA
FACILITY NUMBER: 565850141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above as Creekside memory care residents medications were observed in an unlocked medication cart in the activity room accessible to residents which poses an immediate health risk to persons in care.
POC Due Date: 06/13/2022
Plan of Correction
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Staff locked medication cart during facility visit. Administrator stated that they will provide documentation of staff training regarding regulation 87465(h)(2) to CCL by 6/24/22.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record review, the licensee did not comply with the section cited above as scissors were observed in an unlocked activities directors office accessible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/13/2022
Plan of Correction
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Staff locked activities directors office during facility visit. Administrator stated that they will provide documentation of staff training regarding regulation 87705(f)(1) to CCL by 6/24/22.

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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/13/2022 03:34 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: AEGIS LIVING VENTURA
FACILITY NUMBER: 565850141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as toxic substances were accessible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/13/2022
Plan of Correction
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Staff placed toxic items in an inaccessible location during facility visit. Administrator stated that they will provide documentation of staff training regarding regulation 87705(f)(2) to CCL by 6/24/22.
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4