<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850339
Report Date: 11/21/2024
Date Signed: 11/21/2024 12:07:15 PM

Document Has Been Signed on 11/21/2024 12:07 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:INN AT THE PARK VENTURAFACILITY NUMBER:
195850339
ADMINISTRATOR/
DIRECTOR:		ANGUIANO, ROSEFACILITY TYPE:
740
ADDRESS:21200 VENTURA BLVDTELEPHONE:
(818) 884-7100
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY: 200CENSUS: 174DATE:
11/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Rose AnguianoTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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 Analysts (LPA) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20240306081830). The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. Upon arrival LPA met with Rose Anguiano and explained the reason for the visit.
During the Department’s investigation, the following deficiencies were observed:

On 01/21/2024, at approximately 5:41 p.m., Resident #1 (R1) presented to the emergency department for abdominal pain. The records noted R1 had three days of abdominal pain and diarrhea. On 01/30/2024, the clinical update noted R1 tested positive for C. difficile colitis (C-diff). On 01/31/2024, R1 was discharged from the hospital to the facility with a new medication of Vancomycin to treat the C-diff infection. A review of the facility Medication Assistance Record (MARs) revealed no indication the new prescription for Vancomycin was administered as directed by the hospital.

The facility did not submit a Special Incident Report (SIR) to Community Care Licensing (CCL) to notify that R1 tested positive for C. difficile colitis (C-diff). Additionally, the facility did not submit an exception request for a prohibited health condition, when R1 tested positive for C. difficile colitis (C-diff). R1’s Needs and Services Plan dated 12/26/2023 was not updated to reflect R1’s change in condition and develop a plan of care to meet R1’s needs.

Based on the numerous deficiencies noted during the course of the investigation of complaint 29-AS-20240306081830, the administrator did not demonstrate knowledge of the requirements of Title 22 Regulations, including care and supervision of residents.

Citations issued, exit interview conducted and , appeal rights given.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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 4
Document Has Been Signed on 11/21/2024 12:07 PM - It Cannot Be Edited


Created By: Brian Balisi On 11/21/2024 at 09:08 AM
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: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2024
Section Cited
CCR
87465(a)(4)

1
2
3
4
5
6
7
(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee agreed to submit a plan describing how you will ensure medications are given as prescribed. Submit proof to CCL by due date.
8
9
10
11
12
13
14
Based on records review, the licensee did not comply with section cited above as the Medication Assistance Record (MAR) revealed no indication that Vancomycin was administered as prescribed which posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type A
11/22/2024
Section Cited
CCR87615(a)(4)

1
2
3
4
5
6
7
(a) Persons who require health services... shall not be admitted or retained in a residential care facility for the elderly: (4) Staphylococcus aureus ("staph") infection or other serious infection. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee agreed to submit a plan to ensure exception requests will be submitted for residents who have Prohibited Health Conditions. Submit proof to CCL by due date.
8
9
10
11
12
13
14
Based on records review, the licensee did not comply with the section cited above. Licensee did not submit an exception request for a prohibited health condition when R1 tested positive for C. difficile colitis (C-diff), which posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
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:Brian Balisi
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/21/2024 12:07 PM - It Cannot Be Edited


Created By: Brian Balisi On 11/21/2024 at 09:15 AM
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: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2024
Section Cited
CCR
87211(a)(1)(B)

1
2
3
4
5
6
7
(a)Each licensee shall furnish to the licensing agency such reports...Any serious injury as determined... by the attending physician and occurring while the resident is under facility supervision.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee agreed to submit a plan describing how you will ensure reporting requirements are followed. Submit proof to CCL by due date.
8
9
10
11
12
13
14
Based on records review, the licensee did not comply with the section cited above. Licensee did not submit an incident report when R1 tested positive for C. difficile colitis (C-diff), which posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
11/29/2024
Section Cited
CCR87463(a)(3)

1
2
3
4
5
6
7
The pre-admission appraisal shall be updated, in writing as frequently as necessary ...(3)Any illness... that results in a circumstance or condition specified in... Prohibited Health Conditions.This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee agreed to submit a plan how you will ensure the residents’ needs and services plans are updated when there is a change of condition. Submit proof to CCL by due date
8
9
10
11
12
13
14
Based on records review, the licensee did not comply with the section cited above. Licensee did not update R1’s needs and services plan to reflect R1’s change in condition and develop a plan of care to meet R1’s needs, which posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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:Brian Balisi
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/21/2024 12:07 PM - It Cannot Be Edited


Created By: Brian Balisi On 11/21/2024 at 09:20 AM
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: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2024
Section Cited
CCR
87405(d)(1)(2)

1
2
3
4
5
6
7
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee agreed to submit a plan how you will ensure the facility has a qualified administrator. Submit proof to CCL by due date.
8
9
10
11
12
13
14
Based on records review and interviews, the licensee did not comply with the section cited above. The administrator did not demonstrate knowledge of the requirements of Title 22 Regulations, which posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Brian Balisi
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4