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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850141
Report Date: 07/11/2023
Date Signed: 07/11/2023 05:58:08 PM


Document Has Been Signed on 07/11/2023 05:58 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 NORTH, 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:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Lance ShenkTIME COMPLETED:
06:00 PM
NARRATIVE
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At 09:10 a.m. Licensing Program Analysts (LPAs) Esther Cortez and Ashley Smith, and Licensing Program Manager (LPM) Desaree Perera arrived at the facility unannounced to conduct a required annual visit. The LPAs were greeted by staff and informed them of the reason for the visit. Administrator Lance Shenk arrived shortly after.

At 09:40 a.m. the LPAs and LPM conducted a tour of the physical plant with Administrator Lance Shenk 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 two (2) memory care units, and an assisted living unit. The LPAs and LPM observed fire extinguishers throughout the facility, which were fully charged and last serviced 06/27/2023. The Administrator provided an annual fire alarm testing and inspection report done on 3/31/2023 where all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPAs and LPM observed all required postings in the hallway near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.

Kitchen: During the facility tour at 9:43 a.m., the kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents at the bistro.

Bedrooms: During today’s visit, the LPA observed ten (10) randomly selected resident units. 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.
Report will continue on 809-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
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 07/11/2023 05:58 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: AEGIS LIVING VENTURA
FACILITY NUMBER: 565850141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 as the beauty salon was unlocked with chemicals and cleaning supplies accessible to the residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/11/2023
Plan of Correction
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The administrator locked the beauty salon upon observation.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2023 05:58 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: AEGIS LIVING VENTURA
FACILITY NUMBER: 565850141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 three out of five staff files. One out of five files (S1) only have 3.5 hours out of 40 initial training hours. The LPA was unable to confirm the total four (4) hours of postural support and prohibited health training hours for two out of five files (S2, S3). which poses a potential health and safety risk to persons in care.
POC Due Date: 07/18/2023
Plan of Correction
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The admistrator stated starting 7/13/23, S1, will beging the initial training required and S2, S3 will complete their 4hours of training required. The administrator will submit proof of training to CCL by the end of day of the 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AEGIS LIVING VENTURA
FACILITY NUMBER: 565850141
VISIT DATE: 07/11/2023
NARRATIVE
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Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. Out of the ten (10) bathrooms observed, two (2) toilets required cleaning, and the flooring of one (1) bathroom was unclean. Upon observation, staff cleaned the areas. Water temperature measured in the restrooms ranged between 105.8 degrees Fahrenheit and 117.8 degrees Fahrenheit.

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. At 9:54 a.m. the LPAs and LPM observed four (4) chairs in poor condition in memory care. The Administrator stated new chairs had been ordered and is waiting for arrival. At 10:07 a.m. the LPAs observed a bug crawling on a door in the hallways of memory care. At 10:45 a.m. the LPAs and LPM observed the beauty salon unlocked with chemicals and cleaning supplies accessible to the residents. The Administrator locked the beauty salon upon observation. An electrical room was observed unlocked by LPA Cortez and LPM. The administrator locked the electrical room upon observation. The facility maintained a comfortable temperature of 75 degrees. There were no obstructions and/or tripping hazards throughout the facility.



Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both memory care units’ courtyards and the assisted living courtyard. Parking is available for residents and visitors. The LPAs and LPM 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 were adequate.

Record Review: At 01:15 p.m. a review of facility files was initiated. LPA Smith reviewed five (5) of eighty-four (84) resident files. Out of the five files reviewed, LPA Smith identified that one out of five residents (R1) requires an updated physician’s report, due to the diagnosis of dementia. The LPA advised the Administrator to review R1’s file, as other document indicated that R1 had a diagnosis of mild cognitive impairment (MCI). Otherwise, all resident records were in order. LPA Cortez reviewed five (5) staff files.

Report will continue on LIC809-C

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AEGIS LIVING VENTURA
FACILITY NUMBER: 565850141
VISIT DATE: 07/11/2023
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LPA Cortez reviewed five (5) staff files. Out of the files reviewed, the following was noted: One out of five files (S1) only have 3.5 hours out of 40 initial training hours. The LPA was unable to confirm the total four (4) hours of postural support and prohibited health training hours for two out of five files (S2, S3). Otherwise, the staff files were in order.

Interviews: During today’s visit, the LPAs conducted four (4) resident interviews and three (3) staff interviews. No concerns voiced during the interviews.

Due to time constraints the LPA will return to complete the annual at a later date.

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.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC809 (FAS) - (06/04)
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