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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425800662
Report Date: 04/14/2023
Date Signed: 04/17/2023 11:09:57 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2023 and conducted by Evaluator Kristin Kontilis
COMPLAINT CONTROL NUMBER: 29-AS-20230410085101
FACILITY NAME:VILLA BLANCAFACILITY NUMBER:
425800662
ADMINISTRATOR:INNA LYUTKO & NONNA ROZHKOFACILITY TYPE:
740
ADDRESS:6272 AVENIDA GANSOTELEPHONE:
(805) 683-2000
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:6CENSUS: 6DATE:
04/14/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Nonna RozhkoTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not meet residents' dietary needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced initial 10-day complaint investigation based on the above stated allegation.
Entrance interview conducted:
LPA conducted a physical tour of the facility to ensure health and safety precautions were met. At the time of arrival there were five residents in care and one staff on duty. Administrator Nonna Rozhko arrived at approximately 12:30 pm. Co-Administrator Inna Lyutko arrived at approximately 12:40 pm. LPA explained the purpose of the visit.
During today’s visit, LPA obtained various documents pertinent to the investigation. From 12:25 pm to 1:30 pm, LPA conducted in-person interviews with staff.
On the allegation: Staff do not meet residents’ dietary needs – Reporting Party (RP) stated Resident 1 (R1) was served an omelette that was old and tough to chew. RP stated R1 often had diarrhea. During today’s visit, LPA observed a sour cream container with an expiration date of 3/3/2023 and a piece of spam
Please continue to 812-C, Pg 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 29-AS-20230410085101
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA BLANCA
FACILITY NUMBER: 425800662
VISIT DATE: 04/14/2023
NARRATIVE
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(approximately ½ lb) with visible mold. Based on observation, the allegation that staff do not meet residents’ dietary needs is Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20230410085101
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA BLANCA
FACILITY NUMBER: 425800662
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2023
Section Cited
CCR
87555(b)(28)
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87555(b)(28) General Food Requirements: All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement is not met as evidenced by:
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Contaminated and expired foods were discarded at the time of the visit. POC cleared today.
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Based on observation, the licensee did not comply with the above cited section when LPA observed a piece of spam with mold and an expired container of sour cream, which posed an immediate health and safety risk 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4