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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850141
Report Date: 09/11/2025
Date Signed: 09/11/2025 03:26:37 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2025 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20250825150106
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: 66DATE:
09/11/2025
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:John Washko, General ManagerTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Staff did not ensure adequate supervision was provided resulting in resident sustaining injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findinds for the above noted allegation. LPA was initially greeted by front desk staff. LPA met with General Manager (GM) John Washko and Health Services Director Aleesha Zuniga at 02:53PM Entrance interview conducted.

During an initial complaint visit conducted on 09/02/2025, LPA interviewed GM at 10:38AM, toured the facility at 11:55AM, conducted staff interviews at 10:50AM, 12:27PM, 01:05PM, 02:20PM, and 02:45PM. Additionally, LPA spoke with Resident #1 (R1's) family member telephonically and LPA reviewed and obtained copies of pertinent documents. Throughout the course of the investigation, LPA had a follow up telephone conversation with R1’s family member and LPA reviewed all relevant documents. The following was then determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20250825150106
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/11/2025
NARRATIVE
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The complaint alleges that due to lack of supervision, R1 fell, resulting in hip fracture. LPA reviewed the incident report for the resident’s fall, which indicated that R1 “was seated in common area activity room with care staff present...staff observed [R1] to lose [their] balance and fall to the ground, care staff attempted to stop the fall, but [R1] continued to fall to the ground.” Interviews revealed that during the time of the incident, there were 3 (three) care staff working and 15 (fifteen) residents. Also present were a medication technician and a lead care manager. 1 (one) care staff was on their lunch break, leaving 2 (two) care staff directly supervising the 15 (fifteen) residents. 1 (one) resident had set off an alarm, leaving only Staff #1 (S1) present with the remaining residents. S1 was present in the common area, however was moving the laundry at the time they saw R1 up from their chair and ambulating. S1 stated they saw R1 fall, but they could not stop the fall. Record review revealed that R1 did not require 1:1 supervision and typically R1 did not attempt to stand on their own. Record review revealed that both R1’s physician’s report and R1’s individualized service plan state R1 is independent with transfers. Staff interviewed stated that usually staff would bring R1 their walker and verbally prompt R1 to stand. While staff stated R1 was capable of standing on their own, this was unusual behavior for R1. The family member interviewed indicated that after the fall, R1 was diagnosed with a hip fracture and a urinary tract infection (UTI.) Family member stated that it’s possible R1 was confused due to the UTI, which caused the resident to stand unassisted. Interviews with staff revealed that there are no residents in this memory care unit that require 1:1 supervision. Staff interviewed stated they can visually see residents in the common area when doing laundry; LPA confirmed the proximity of the laundry area to the area R1 was seated at the time of the incident. Although R1 did fall resulting in a hip fracture, R1 did not require direct supervision at all times and staff were present at the time of the incident. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not ensure adequate supervision was provided resulting in resident sustaining injury” is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. A copy of today’s report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC9099 (FAS) - (06/04)
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