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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609944
Report Date: 12/13/2021
Date Signed: 12/13/2021 03:02:53 PM

Document Has Been Signed on 12/13/2021 03:02 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:LA VENTANA TREATMENT PROGRAMSFACILITY NUMBER:
567609944
ADMINISTRATOR:KLEIN, DIAHANNFACILITY TYPE:
772
ADDRESS:2479 LA GRANADA DRIVETELEPHONE:
(805) 371-1274
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY: 6CENSUS: 3DATE:
12/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Rebekah Sanchez NortonTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #29-AS-20201113113519.

While conducting interviews, the LPA reviewed the Department clearance list to confirm that staff were associated to this facility. to the Department clearance list and identified three employees (Staff #1, Staff #2, Staff #3) that had fingerprint clearance, yet were working without a clearance transfer to this facility.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted, today's reports and appeal rights were reviewed and issued. Civil penalties assessed.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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 2
Document Has Been Signed on 12/13/2021 03:02 PM - It Cannot Be Edited


Created By: Ashley Smith On 12/13/2021 at 02:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LA VENTANA TREATMENT PROGRAMS
FACILITY NUMBER: 567609944

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2021
Section Cited
CCR
81019(e)(1)

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81019(e)(1) Criminal Record Clearance. All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
This requirement is not met as evidenced by:
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The Licensee Representative agrees to do the following:
1. Submit appropriate paperwork the three staff and confirm that the staff are associated to the facility prior to allowing them to return to work.

Civil penalties assessed.
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Based on record review, the Licensee did not comply with the section cited above, as there were three staff (S1, S2, S3) working whom were not associated to this facility, which poses an immediate health and safety risk to clients in care.
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Staff were associated while the LPA was at the facility. LPA checked the Guardian Caregiver Background Check portal and confirmed all three associations. Plan of Correction met.

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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2021


LIC809 (FAS) - (06/04)
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