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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850339
Report Date: 08/15/2023
Date Signed: 08/15/2023 01:12:46 PM

Document Has Been Signed on 08/15/2023 01:12 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:INN AT THE PARK VENTURAFACILITY NUMBER:
195850339
ADMINISTRATOR:ANGUIANO, ROSEFACILITY TYPE:
740
ADDRESS:21200 VENTURA BLVDTELEPHONE:
(818) 884-7100
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY: 200CENSUS: 161DATE:
08/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:43 PM
MET WITH:Rose AnguianoTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20230807131405). The purpose of the visit is to issue a citation for deficiency observed during the complaint investigation.

During the complaint investigation of complaint # 29-AS-20230807131405, the following deficiency was observed: On 08/05/2023, Resident #1 (R1) was brought back to the facility by law enforcement after finding R1 outside of the community looking lost, disoriented, and disheveled. However, facility staff refused to re-admit R1 back into the facility.

Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC LIC9099-D). Failure to correct citations can result in civil penalties.

Exit interview conducted. Citation issued. A copy of the Appeal Rights and Report was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
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 08/15/2023 01:12 PM - It Cannot Be Edited


Created By: Martha Arroyo On 08/15/2023 at 01:04 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: INN AT THE PARK VENTURA
FACILITY NUMBER: 195850339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2023
Section Cited
CCR
97507(g)(10)

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The requirements pertaining to the involuntary transfer or eviction of residents, including: The justification, worded exactly as shown in the applicable state law or regulation, that permits an eviction. This requirement is not met as evidenced by:
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The Licensee has agreed to review Regulation 87224 Eviction Process and submit statement of understanding to CCL by 08/31/2023.
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Based on record review and interviews, the licensee did not comply with the section cited above as R1 was refused entry to the facility after being brought back to the facility, which poses a potential health, safety, and personal rights violation to residents in care.
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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 Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023


LIC809 (FAS) - (06/04)
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