565850175-8-20-2021-29-AS-ASMH-C63P6T-20210820110249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850175
Report Date: 08/20/2021
Date Signed: 08/20/2021 11:03:26 AM

Document Has Been Signed on 08/20/2021 11:03 AM - 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:	LA VENTANA TREATMENT PROGRAMS		FACILITY NUMBER:	565850175
ADMINISTRATOR:	VOLNER, SHARON		FACILITY TYPE:	772
ADDRESS:	965 RANCHO ROAD		TELEPHONE:	(818) 584-5615
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY: 6		CENSUS: 0	DATE:	08/20/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Steve Zamarripa		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ashley Smith arrived at the facility announced at 10:00am to conduct a pre-licensing inspection. The LPA met with applicants Steve Zamarripa and Sharon Volner. The home has the capacity for six ambulatory clients. The fire clearance was granted on 07/02/2021; in which rooms were cleared for ambulatory clients with a latched perimeter only. The LPA toured the physical plant areas inside and outside with applicants to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. BEDROOMS: Whereas the facility has six (6) rooms, the facility has designated three (3) shared bedrooms for clients. All rooms are set up with beds, night stands, lamps, chests of drawers and closet space. Client Room #1 has a direct exit to the outside. Lighting in the rooms appeared adequate. Client Room #3 has a fireplace, which is inoperable and will be gated. BATHROOMS: There are three (3) bathrooms for client use; the half bathroom in the hallway is a designated for staff . Two out of the three client rooms has an attached bathroom, and the other client full bathroom is in the hallway. The client tubs are equipped with nonskid surfaces. Grab bars were observed in the bathrooms. COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. The facility smoke alarm system is hard wired; the smoke detectors were tested at 10:20am and were operable at the time of the visit. There are four fully charged fire extinguishers. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted throughout the facility. Emergency telephone numbers are posted in the kitchen. Other required postings are posted in the hallway upon entry into the facility

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

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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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: LA VENTANA TREATMENT PROGRAMS	FACILITY NUMBER: 565850175
	VISIT DATE: 08/20/2021

NARRATIVE

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KITCHEN: Kitchen knives are stored locked and inaccessible in the medication closet in the hallway. The supply of nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. There is an adequate supply of emergency food.

MEDICATIONS: Medications will be in a locked closet in the hallway. The first aid supplies were complete. First aid kits will be stored locked with the medications and there are additional kits throughout the facility.

THERAPY AND STAFF: The additional three rooms include an Isolation Room (equipped with a Personal Protection Equipment (PPE) Station outside the room), a Group Room, and a Staff Room. Group and individual therapy will take place in the Recreational Room, Group Room, Living Room, and the outdoor space. Staff files will be kept in the Staff room. Client files will be stored electronically. Facility will have awake staff only; there are no staff sleeping quarters on the property.

LAUNDRY: The laundry area is in the hallway. Laundry detergent will be stored inaccessible in the garage.

GARAGE AND GROUNDS: The garage is accessible from the house but is designated as the Recreational Room. Personal hygiene items (shampoos, soaps) and toxic items stored in inaccessible the garage. There are additional linens and towels in the garage cabinets. The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs where clients can sit. There is a storage shed in the backyard. There are no bodies of water on the premises at the time. There is an eight passenger van on the premises for transportation use.

INFECTION CONTROL: The facility confirmed that they will have a central entry point for symptom screening and sanitation station for staff, clients and visitors. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The physical plant of this facility location is in compliance with Title 22 regulations at this time.

Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC809 (FAS) - (06/04)

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