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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850281
Report Date: 03/20/2024
Date Signed: 03/20/2024 05:07:52 PM


Document Has Been Signed on 03/20/2024 05:07 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:NAVITA RESIDENCES TULLFACILITY NUMBER:
565850281
ADMINISTRATOR:VIJAYAKUMAR, KARTHIGAFACILITY TYPE:
740
ADDRESS:5603 TULL STTELEPHONE:
(805) 494-4121
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 5DATE:
03/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted a Case Management - Incident visit to the this facility. Upon arrival LPA met with staff and reason for visit was explained. Staff contacted Administrator who arrived at approximately 4pm. Reason for the visit was discussed with the Administrator Kathiga V.

The facility self-report an incident, noting that on 03/08/2024, resident #1 (R1) suffered a fall in the private room, which resulted in fractured hip and hospitalization. According to the staff, they heard noises from R1's room and found R1 sitting on the carpet. R1 reported to staff that they lost their balance. it was also noted that staff checked R1's body, found no bruises, but R1 was in pain so staff gave R1 pain medication and R1 went to bed. According to staff and Administrator R1 slept well through the night. However, in the morning, R1 complained of having pain, therefore Administrator called 911 and paramedics took R1 to Community Memorial Hospital. R1 sustained a fractured left hip and undergone surgery.

During today's visit, LPA and staff toured the facility which consist of six (6) resident bedrooms, three (3) bathrooms, garage, and kitchen at approximately 3:15pm. Also during todays visit LPA conducted a file review at approximately 3:30pm and obtained pertinent documentation relating to R1. Interview with staff and Administrator was held regarding this incident at approximately 4pm. According to staff and Administrator R1 was not considered a fall risk; R1 was able to ambulate with a walker with no assistance. According to Administrator and staff no history of any other falls at the facility for R1 since date of admission 02/10/2018.

Prior to issuing final licensing report, it has been determined that further investigation is needed at this time. This case was referred to Community Care Licensing Investigation's Branch (IB) for further investigation.

Exit Interview Conducted and Report was Issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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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